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ABDOMINAL  HERNIA 

ITS 

DIAGNOSIS   and   TREATMENT 


BY 

W.  B.   De  GARMO,  M.D., 


NEW    YORK. 


Professor  Special  Surgery  (Hernia),  New  York  Post-Graduate  Medical  School  and  Hospital; 
Fellow  New  York  Academy  of  Medicine  j    Member  American  Medical  Associ- 
ation,  New  York  State  and  County  Medical  Societies,   Honorary 
Member  of  the  Medical  Society  of  Virginia. 


PHILADELPHIA    a^  LONDON 

J.  B.  LIPPINCOTT    COMPANY 


K  U 


Copyright,  1907 
By  J.  B.  LippiNcoTT  Company 


Electrotyped  a7id  Printed  by  J.  B.  Lippincott  Company 
The  Washingiofi  Square  Press,  Philadelphia,  U.  S.  A. 


DEDICATION 

TO  the  many  practitioners  of  medicine 
and  surgery  who,  during  the  past 
twenty  years  at  the  New  York  Post-Graduate 
Medical  School  and  Hospital,  have  patiently 
followed  the  Author's  attempts  to  simplify 
the  teaching  of  hernia,  this  work  is  dedicated. 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/abdominalherniaiOOdega 


PREFACE. 


The  first  appeal  for  aid  by  those  afflicted  with  hernia,  is 
usually  made  to  the  family  physician. 

While  the  surgeon  has  plenty  of  literature  to  guide  him 
in  his  part  of  the  work,  the  physician,  upon  whom  many  times 
the  full  responsibility  of  the  case  must  rest,  finds  little  practical 
aid  from  that  source  in  any  language.  It  is  t(j  the  physician 
that  this  book  is  especially  addressed,  and  if  it  fails  to  furnish 
him  useful  suggestions  regarding  the  diagnosis  and  treatment 
of  adominal  hernia,  then  certainly  it  will  have  fallen  far  short 
of  its  intent. 

The  author's  severest  critic  will  scarcely  accuse  him  either 
of  writing  a  book  too  early  in  his  professional  career,  or  of 
compiling  one  from  the  experience  of  others.  Many  authors 
have  been  consulted,  and  quoted  with  credit,  but  the  funda- 
mental part  of  the  work  is  based  upon  personal  experience, 
and  the  illustrations  are  largely  from  photographs  of  patients 
under  treatment. 

The  author  realizes  his  liability  to  criticism  for  omitting 
mention  of  other  forms  of  operation,  popular,  perhaps,  in  the 
country  of  their  origin;  but  he  justifies  himself  in  the  fact  that 
they  have  not  shown  the  success,  that  has  followed  the  use  of 
those  here  given.  Furthermore  he  has  tried  to  make  clear  the 
principles  involved  in  curative  measures  rather  than  to  suggest 
any  special  method. 

Acknowdedgment  of  obligations  to  many  friends  is  freely 
given,  especially  the  following  who  wdllingly  granted  the  use 
of  original  drawings  which  are  a  valuable  addition  to  the  text : 
Dr.  W.  S.  Halsted,  Baltimore;  Dr.  W.  J.  Mayo.  Rochester, 
Minn. ;  Dr.  William  S.  Bainbridge,  New  York ;  Dr.  Charles 
N.  Dowd,  New  York;    Dr.  A.  E.   Halstead,  Chicago;    Dr. 


6  PREFACE. 

W.  Jay  Seaver,  New  Haven;  Dr.  Samuel  W.  Kelly,  of  Cleve- 
land, and  to  Professor  Julius  A.  Becker  for  special  dissections 
from  which  Mr.  K.  K.  Bosse  has  drawn  some  of  the  anatom- 
ical plates,  and  to  Dr.  Alfred  M.  Hellman  for  compiling  the 
index. 

Manufacturers  of  appliances  for  the  relief  of  hernia  have 
allowed  the  publishers  to  draw  freely  upon  them  for  electro- 
types, with  which  to  illustrate  different  forms  of  trusses,  and 
the  author  wishes  to  thank  in  this  public  manner,  Wm.  H. 
Horn  &  Bro.,  The  J.  Ell  wood  Lee  Co.,  Chesterman  &  Streeter, 
and  his  brother  Mr.  G.  J.  De  Garmo. 


CONTENTS 


CHAPTER  PAGE 

I.     Surgical  Anatomy  of  the  Inguinal  Region 17 

II.     Descent  of  the  Testicle 34 

III.  Cause  of  Inguinal  Hernia 44 

IV.  Types  and  Conditions  of  Inguinal  Hernia 54 

V.    The  Hernial  Sac 71 

VI.  Symptoms  and  Diagnosis  of  Inguinal  Hernia    ....      82 

VII.  Mechanical  Treatment  of  Inguinal  Hernia     ....    114 

VIII.     Truss  Fitting 152 

IX.  Mechanical  Treatment   of    Inguinal   Hernia   in   In- 
fancy and  Childhood 189 

X.  Treatment  of  Inguinal  Hernia  by  Gymnastics    .    .    .    204 

XL    Surgical  Cure  of  Inguinal  Hernia 214 

XII.  Complications    in    the    Surgical    Cure    of    Inguinal 

Hernia ,    .    239 

XIII.  Sigmoid,  C^cal  and  Bladder  Hernia 277 

XIV.  Surgical  Cure  of  Inguinal  Hernia  in  the  Female    .    292 
XV.    Femoral  Hernia     297 

XVI.     Mechanical  Treatment  of  Femoral  Hernia 317 

XVII.     Surgical  Cure  of  Femoral  Hernia 331 

XVIII.     Umbilical  Hernia 344 

XIX.  Mechanical  Treatment  of  Umbilical  Hernia  ...    355 

XX.     Surgical  Cure  of  Umbilical  Hernia 372 

XXI.     Ventral  Hernia .    383 

XXII.     Rare  Forms  of  Hernia 39S 

XXIII.  Contra-Indications  to  the  Surgical  Cure  of  Abdom- 

inal Hernia 409 

XXIV.  Strangulated  Inguinal  Hernia 413 

XXV.  Medical  Treatment  of  Strangulated  Hernia     ....    427 

XXVI.  Surgical  Treatment  of  Strangulated  Inguinal  Hernia  432 

XXVII.     Strangulated  Femoral  Hernia 439 

XXVIII.     Strangulated  Umbilical  Hernia 443 


ILLUSTRATIONS 


FIGURR  PAGE 


4- 

5- 

6. 

7- 
8. 

9- 

10. 

II. 

12. 

13- 
14. 

IS- 

16. 

17- 
18. 

19. 
20. 
21. 
22. 

22- 
24. 

25- 

26. 
27. 
28. 
29. 
30. 

31- 
32. 
33- 


Original    drawing.)      Showing  position   of   superficial   vessels..  21 
Original  drawing.)     Aponeurosis  of  external  oblique  muscle  and 

external    ring    22 

Original  drawing.)     Aponeurosis  opened  to  show  deep  part  of 

canal     24 

Cooper.)     Anatomy  of  inguinal  and  femoral  region 25 

Original    drawing.)       Proximity    of    deep    epigastric    and    iliac 

arteries    to    inguinal    canal 30 

Leidy.)      The    greater    omentum 32 

GoDARD   from    Eccles.)      Partial    descent   of   testicle 35 

GoDARD  from  Eccles.)     Partial  descent  of  testicle 2>^ 

Eccles.)      Testicle   in   Scarpa's   triangle 27 

Original  photo.)     Right  testicle  in  canal,  left  at  internal  ring.  .  38 

Original   drawing.)      Multiple   cysts   of  cord 40 

Original    photo.)      Hydrocele    of    cord    simulating    irreducible 

hernia    41 

Macready.)      Side  view  of  abdomen  of  old  man 46 

Macready.)      Early    inguinal    hernia 48 

Original   drawing.)      A  form  of  physical   culture  that  produces 

hernia    52 

Macready.)      Double  oblique   and   direct   hernise 55 

Eccles.)      Incomplete    inguinal    and    direct    hernise 56 

Original   photo.)      Right   complete   inguinal   and   enormous   left 

scrotal    hernias    57 

Original  photo.)      Scrotal  hernia  of  enormous  size 58 

Original   photo.)      Labial   hernia   in   woman 59 

Macready.)      Double    direct   hernia 60 

Original   photo.)    Sigmoid   hernia 61 

Original  photo.)     Right  direct  and  left  sigmoid  hernije 62 

Original  photo.)     Left  interstitial  hernia,  right  testicle  in  canal.  63 

Eccles.)      Right  interstitial  hernia  with  retained  testicle 64 

Eccles.)     Right  testis  in  cruro-scrotal  pouch  with  hernia 65 

Macready.)      Right  interstitial   hernia  with   retained  testis....  66 

Macready.)     Left  interstitial  hernia  simulating  femoral  hernia.  67 

Original   drawing.)      Showing  formation   of  interstitial   sac...  68 

Original  drawing.)     Three  fibrous  rings  in  acquired  sac 72 

Original   drawing.)      Two   fibrous   rings   with    strangulation    in 

upper    one    72 

Original    drawing.)      Omentum    incarcerated    in    ring    in    Con- 
genital   sac    74 

Macready.)     Hernia  in  funicular  portion  of  tunica  vaginalis..  75 

9 


10 


ILLUSTRATIONS. 


FIGURE  PAGE 

34.  (Original    drawing.)      Hernia   into    funicular   portion   of   tunica 

vaginalis    with    cyst    below "^6 

35.  (Original   drawing.)      Infantile   sac   with   closed  tunica  vaginalis 

below "jy 

36.  (Original  drawing.)      Sac  of  peculiar  shape 78 

2,7.   (Original    drawing.)      Interstitial    sac 79 

38.  (Original  drawing.)     Relative  thickness  of  tissues  covering  sac.  80 

39.  (Original  photo.)     Irreducible  omental  scrotal  hernia 83 

40.  (Original    photo.)      Large    reducible    scrotal    hernia 84 

41.  (Original     drawing.)        Improper     method     of     examining     for 

hernia     87 

42.  (Original  photo.)      Enormous  irreducible  left  scrotal  hernia....     89 

43.  (Original    photo.)      Large    scrotal    hernia    with    true    peritoneal 

sac     90 

44.  (Original  photo.)      Typical  congenital  hernia  in  adult 92 

45.  (Original  photo.)      Double  congenital  hernia  in  boy 93 

46.  (Original  photo.)     Double  congenital  hernia  mistaken  for  h}-dro- 

cele    93 

47.  (Original  photo.)      Double   congenital   hernia  retained  by  truss.     94 

48.  (Original  photo.)       Double    congenital    hernia    two    years    after 

operation     95 

49.  (Original  photo.)      Tj-pical   scrotal  hernia  of  acquired  type 96 

50.  (Original  photo.)      Right  labial  hernia    97 

51.  (Original  photo.)      Right  labial  hernia,   four  weeks  after  opera- 
tion       98 

52.  (Original  photo.)      Sigmoid   hernia    99 

53.  (Original  photo.)      Caecal    hernia    lOO 

54.  (Original  photo.)      Sigmoid  and  Caecal  hernia  in  same  patient.  .  loi 

55.  (Original  photo.)      Csecal   hernia  in   woman loi 

56.  (EccLES.)     Left  varicocele  and  femoral  varix 103 

57.  (Original  photo.)     Varicocele  mistaken  for  hernia 105 

58.  (Le  Progre's  Med.,  redrawn.)     Statuette  showing  truss.  900  B.  C.  115 

59.  (Original   drawing.)      Showing  shape  of  pelvis 122 

60.  (Original   photo.)      Illustration  of  bad  truss-fitting 127 

61.  Original  photo.)       Properly    applied    truss 128 

62.  (Original  photo.)     Usual  manner  of  applying  German  truss....  129 

63.  (Original  drawing.)      Position   in   which   a   truss    spring   should 

be   applied    130 

64.  (Original  photo.)      De   Garmo-Hood   truss    applied 140 

65.  (Original  photo.)     De  Garmo-Hood  truss  applied,  back  view.  .   141 

66.  Group  of  variously  shaped   pads    (thirteen   figures) 149 

(yj.  A   standard  of  sizes   for   truss  pads    (four  figures) 150 

68.  (Macready.)      Measuring  for   inguinal   truss I53 

69.  (Original   drawing.)    Methods  of  taking  diagram  with  lead  tape  154 

70.  (Original  drawing.)     Method  of  taking  diagram,  second  position  155 

71.  (Original  drawing.)     Pelvic    diagrams    contrasting   shape 156 


ILLUSTRATIONS.  1 1 


72.  (Original  drawing.)     Pelvic   diagrams   contrasting   shape 157 

73.  Shaping    truss    springs     (seven    figures) 159-160 

74.  (Horn.)      Hard-rubber   cross-body   truss   applied 161 

75.  (Original  photo.)     Large    labial    hernia 162 

y6.   (Original  photo.)     Labial   hernia   retained  by  cross-l)ody  truss..  163 

77.  (Horn.)      Hard-rubber    Hood    truss    applied 164 

78.  (Original  photo.)     Recurrent  hernia  in  woman 164 

79.  (Original  photo.)     De    Garmo-Hood   truss    applied    to    recurrent 

hernia     165 

80.  (Original  photo.)     Large  double  hernia    166 

81.  (Original  photo.)     Large  double  hernia  retained  l)y  Hood  truss.  167 

82.  (Horn.)      Combination  of  radical-cure  truss  with  ordinary  dou- 

ble   truss     168 

83.  (Macready.)      English  "  Rat-tail  "  truss,  applied 170 

84.  (EccLES.)      English  double  truss,  applied 171 

85.  (Horn.)     Hard-rubber  French  truss,  applied 172 

86.  (Original  photo.)     Double    retained     testes     and     hernia;     truss 

applied     1 78 

87.  (Original  photo.)     Double    retained    testes    and    hernia 179 

88.  (Macready.)      Truss   for    reducible   interstitial   hernia 181 

89.  (Original  photo.)     Large   irreducible   scrotal   hernia 184 

90.  (Macready.)      Hinged-cup  truss    for   irreducible   hernia 185 

91.  (Original  photo.)      Enormous   irreducible   left   scrotal   hernia....  i85 

92.  (Original  drawing.)     Method    of    supporting    large    inreducible 

hernia     187 

93.  (Original  drawing.)      Five-weeks-old   boy   with   cross-body   truss 
applied     191 

94.  (Original  drawing.)     Hood's  truss  applied  to  girl  six  months  old  192 

95.  (Original  photo.)      Cross-body   hard-rubber    truss 193 

96.  (EccLES.)     Hank  of  worsted  truss 194 

97.  (Original  photo.)      Cross-body    hard-rubber    truss    with    perineal 

strap     195 

98.  (Original  photo.)     De    Garmo-Hood    truss   on   girl 196 

99.  (Original  photo.)      De  Garmo-Hood  truss   on  boy 197 

100.   (Original  photo.)     German   scrotal   hernia   truss   on  boy 198 

lOi.   (Seaver.)      Gymnastic    exercise    no.    i 205 

102.  (Seaver.)     Gymnastic    exercise    no.    2 206 

103.  (Seaver.)      Gymnastic   exercise    no.    3 206 

104.  (Seaver.)      Gymnastic   exercise   no.    4 207 

105.  (Seaver.)     Gymnastic   exercise   no.    5 208 

106.  (Seaver.)     Gymnastic    exercise    no.    6 208 

107.  (Seaver.)     Gymnastic    exercise    no.    7 209 

108.  (Seaver.)     Gymnastic   exercise   no.   8 210 

109.  (Original  drawing.)      Sac  separated   from   cord   and   anatomy   of 

inguinal     region     221 

no.    (Original  drawing.)     Curved   blunt   needle    223 


12 


ILLUSTRATIONS. 


FIGU 
III. 

112. 

113- 

114. 

115- 
116. 
117. 
118. 
119. 
120. 
121. 

122. 
123. 
124. 

125- 

126. 
127. 

128. 

129. 

130. 

131- 
132. 

133- 

134- 
135- 

136. 

137- 
138. 
139- 

140. 

141. 
142. 

143- 
144. 

145- 
146. 

147- 
148. 


RE  PAGE 

(Original  drawing.)     Internal     oblique     stitched     to     Poupart's 

ligament     224 

Original  drawing.)     Aponeurosis  closed  by  continuous   suture.   225 
Halsted.)     Relative  position  of  sac,  cord  and  vas  deferens...   229 

Halsted.)     Cremaster   fastened  under  internal   oblique 230 

Halsted.)     Internal  oblique  fastened  to   Poupart's   ligament...   231 

Halsted.)      Overlapping  of  aponeurosis    (first  step) 232 

Halsted.)      Overlapping  of  aponeurosis    (second   step) 233 

Halsted.)      Sectional   view   of   fascial   layers 234 

WullsteiNj  redrawn.)     Transplanting  of  cord    (first  step)....  235 
Wullstein,  redrawn.)     Transplanting  of  cord   (second  step)..  236 
Halsted.)     Halsted's     method     of     utilizing     split     sheath     of 
rectus     237 


Origina 
Origina 
Origina 
Origina 
Origina 

tion 
Origina 
Origina 
Origina 
Origina 
Origina 
Origina 
Origina 

them 
Origina 
Origina 

tion 
Origina 

be  a 
Origina 
Origina 
Origina 

sac  . 
Origina 

sac  . 
Origina 
Origina 
Origina 
Origina 
Origina 
Origina 
Origina 
Origina 


drawing.)  Right  retained  testicle  in  boy  of  10  years.  240 
photo.)  Right  retained  testicle  in  boy  of  9  years....  241 
photo.)     Double   retained  testes  in  boy  of   13   years.  .   241 

drawing.)     Delayed    testicle    surrounded    by    sac 242 

photo.)     Double  retained  testes  two  years  after  opera- 

243 

photo.)     Retained  left  testicle  and  interstitial  hernia.  244 

photo.)      Sac   of   interstitial   hernia   before   opening...  245 

photo.)     Sac   with   testicle    inside 246 


drawing.) 
drawing.) 
drawing.) 
drawing.) 


Retained    testicle,    sac    opened 247 

Purse-string    suture    in    sac 247 

Sac    tied    by    purse-string    suture 248 

Lifting   muscles    to   place   testicle    beneath 

249 

photo.)     Interstitial  hernia  and  retained  testicle 250 

photo.)     Interstitial   hernia    three    weeks    after   opera- 

251 

photo.)     Double  hernia  in  child  of  7  years  supposed  to 

jirl    252 

photo.)      Same  as  preceding,  with  hernia  reduced....  253 

photo.)      Same   as   preceding 255 

drawing.)     Appendix    adherent    to    anterior    wall    of 

257 

drawing.)     Appendix    adherent    to    posterior    wall    of 

259 

drawing.)     Appendix  incarcerated   in  fibrous   ring....  260 


photo, 
photo, 
photo, 
photo, 
photo, 
photo, 
photo. 


Sac  and  omentum  removed  together 262 

Omentum  spread  out  for  ligating 263 

Omentum    irreducible     from     shape 264 

Omentum,    hypertrophied    265 

Omentum  and  sac   266 

Scrotal  hernia  to  within  two  inches  of  knee.  .  268 

Side  view  of  preceding  case 269 


ILLUSTRATIONS.  l.'J 

FIGURE  PAGE 

149.  (Original  photo.)  Preceding  cape  seven  weeks  after  operation.   270 

150.  (Original  photo. j  Large  scrotal  hernia  containing  bladder....  2~\ 
Original  photo.)  Preceding  case  six  weeks  after  operation..  272 
Original  photo.)  Preceding   case   five   years    later   with    hernia 

on    opposite    side     273 

Original  photo.)      Enormous  scrotal  hernia  in  man  of  70  years  274 

Original  photo.)  Irreducible  scrotal  hernia,  intestine  only....  275 
Original    drawing.)       Peculiar    mesentery    found    in    preceding 

case     276 

Original  drawing.)     Hernial    sac    containing    free    caecum    and 

loops    of   intestine 278 

Original  drawing.)      Hernial    sac    in    front    of    cjecum 279 

Original  drawing.)      Form   of   purse-string    suture   for    sigmoid 

sac     281 

Original  drawing.)      Lifting   internal   oblique  to  bury  stump  of 

sac     282 

Original  drawing.)      Protrusion    consisting    of    hernial    sac    and 

bladder     287 

Original  drawing.)  Hernial  sac  and  bladder  protruding  sep- 
arately       289 

Original  drawing.)      Closure  of  canal  in  female  by  single  suture  294 

Original  drawing.)     Anatomy    of    femoral    region 298 

Original  drawing.)  Transverse  section  of  femoral  region....  299 
Redrawn    from   Gray.)      Showing   relative   position   of    femoral 

hernia   and   large   vessels 301 

Original  photo.)     Double  femoral  hernia  in  man  of  50  years.  .  302 

Original  photo.)     Reducible   femoral  hernia   of  enormous   size.  303 

Original  photo.)     Irreducible    femoral    hernia 305 

Original  photo.)      Double    femoral    hernia   in   woman 306 

Original  drawing.)      Cystic    femoral    sac    307 

Original  photo.)      Femoral  hernia  of  peculiar  shape,  in  woman.  308 

EccLES.)     Left   varicose    saphena    vein 312 

Original  photo.)      Femoral  and  labial  varix  in  pregnant  woman 

of    35    years    313 

Original  photo.)     Lipoma     simulating    femoral    hernia 315 

Original  photo.)      Femoral   hernia   in   woman,   cross-body   truss 

applied     2^2 

Original  drawing   from   photo.)      Cross-body   hard-rubber   truss 

for    femoral    hernia    323 

Redrawn.)     German    femoral    truss    applied 325 

Redrawn  from  M.a.cready.)  English  femoral  truss  applied...  326 
Original    drawing    from    photo.)     Adjustable    truss    applied    to 

femoral    hernia     327 

180.  (Original  drawing  from  photo.)  De  Garmo  femoral  truss  ap- 
plied      328 


U  ILLUSTRATIONS. 

FIGURE  PAGE 

i8i.   (Original  photo.)     Inguinal  and  femoral  hernia  in  woman.,  truss 

applied     329 

182. 
183. 


184. 
185. 
186. 
187. 
188. 

189. 
190. 
191. 
192. 

193- 
194. 

195- 
196. 

197. 
198. 
199. 
200. 
201. 
202. 
203. 

204. 

205. 
206. 
207. 
208. 
209. 
210. 
211. 
212. 
213. 
214. 

215- 

216. 
217. 
218. 
219. 

220. 


Original  drawing.)  Location  of  incision  for  femoral  hernia...  334 
Original  drawing.)      Showing    femoral    protrusion    under    Pou- 

part's  ligament    335 

Original  drawing.)  Femoral  operation;  sac  drawn  down....  336 
Original  drawing.)  Femoral  hernia  operation,  sutures  in  place  337 
Original  drawing.)  Femoral  hernia  operation  sutures  tied..  338 
Original  drawing.)  Femoral  hernia  operation;  blunt  needle..  339 
Original  photo.)     Double   reducible   femoral   hernia,   woman   of 

60   j-ears    339 

Original  photo.)      Same    case,    side    view 340 

Original  photo.)      Same    case    six    weeks    after    operation 341 

Original  photo.)      Femoral    hernia    of    unusual    type 342 

Original  photo.)     Umbilical    hernia    in   child   of   3    years 347 

Original  photo.)     Enormous    irreducible    umbilical    hernia 348 

Original  photo.)     Same  case,  side  view 349 

Original  photo.)  Enormous  umbilical  hernia;  man  of  45  years  350 
Original  photo.)     Reducible     umbilical     hernia     in     200-pound 

woman     350 

Original  photo.)     Irreducible  umbilical  hernia  in  woman 351 

Original  photo.)     Irreducible    umbilical    hernia    in    man 351 

Bainbridge.)      Multiple    hernije    352 

Bainbridge.)  Same  case  showing  5  hernise  in  median  line....  353 
Dr.  S.  W.  Kelly.)     Plate  and  plaster  for  umbilical  hernia....   356 

Dr.  S.  W.  Kelly.)      Plate  and  plaster  applied 357 

Original  photo.)     Truss  applied   for   umbilical   hernia,   child  of 

3    years     359 

Horn.)     Outlines   of   umbilical   plates 366 

Continued.), Size   of   umbilical   plates 367 

EccLES.)     An    English   umbilical    truss 368 

Horn.)     Diagram    for   abdominal    belt    measure 369 

EccLES.)     English  rim-plate  concave  umbilical  truss 370 

Original  drawing.)     Vertical   overlapping   of   abdominal   wall.  .   376 

Mayo.)     Transverse   elliptical   incision    37S 

Mayo.)     Transverse  overlapping  sutures  in  place 379 

M.\YO.)     Transverse  overlapping,  complete   380 

Original  photo.)      Post-operative    ventral    hernia 387 

Original  photo.)  Deposit  of  fat  simulating  ventral  hernia....  388 
Original  photo.)     Ventral   hernia   following   gun-shot   wound.  .   389 

Original  photo.)      Same,    front    view 390 

Original  photo.)     Bilateral    post-operative    ventral    hernia 391 

Original  photo.)     Ventral   hernia   after   appendix   operation....   393 

Macready.)      Spontaneous    double    lumbar    hernia 399 

Macready.)     Truss   for   right  lumbar  hernia 400 

DowD. )      Congenital    lumbar   hernia    401 


ILLUSTRATIONS.  1.5 

FIGURE  PAGE 

221.  (DovvD.)     Anatomy    of    congenital    lumbar    hernia 402 

222.  (DovvD.)     Operation    for    lumbar    hernia    sutures    placed 40,3 

223.  (DowD. )      Operation  for  lumbar  hernia  sutures  tied 404 

224.  (Original  photo.)      Exstrophy    of   bladder   and   vaginal    hernia..   406 

225.  (Original  photo.)      Same    case    with    appliance 407 

226.  (Horn.)     Appliance    for    perineal    hernia    408 

Classification  of  Trusses  by  Groups. 

Group  of: 

Springless  trusses    (seven  figures) 119-120 

French,  German  and  English  trusses   (eight  figures) 125-126 

Cross-body   type   of   trusses    (eight   figures) 131-132 

Chase  type  of  trusses   (eight  figures) 133-134 

Hood   type   of   trusses    (Twelve   figures) ,.  . .  137-13Q 

Unclassified  trusses    (four  figures) 143-144 

Double   trusses    (ten   figures) 145-146 

Trusses  for  femoral  hernia   (sixteen  figures) 318-321 

Infant  umbilical  trusses   (nine  figures) 358 

Adult   umbilical  trusses    (eighteen   figures) 361-365 

Trusses  for  ventral  hernia  (six  figures 394-395 

Diagrams    (original  drawing)    showing   formation  of  femoral  hernia, 
extra-peritoneal  fat  and  lipoma 300 


ABDOMINAL   HERNIA 

ITS 

DIAGNOSIS  AND   TREATMENT. 


CHAPTER  I. 


INTRODUCTION. 


Definition. — Hernia  is  the  protrusion  from  a  cavity,  of 
any  of  its  natural  contents ;  as  hernia  of  the  brain  from  the 
cranial  cavity,  or  hernia  of  the  lung  from  the  cavity  of  the 
chest.  Abdominal  hernia  is,  therefore,  the  protrusion  through 
the  retaining  wall  of  any  of  the  enclosed  viscera.  This  gen- 
erally occurs  at  some  point  in  the  muscular  wall  that  is  weak- 
ened by  the  transmission  of  nerves  and  blood  vessels,  at  points 
congenitally  defective,  or  through  muscular  parts  that  have 
been  previously  lacerated  or  incised. 

The  word  "  Rupture^'  so  commonly  used  to  denote  a  con- 
dition of  hernia,  will  be,  as  far  as  possible,  avoided  in  this 
work,  as  it  leads  to  an  erroneous  impression  of  what  actually 
occurs.  In  the  early  ages  this  term  was  applied  under 
the  supposition  that  there  was  actual  rupture  of  the  peri- 
toneum. It  is  now  well  known  that  there  is  rarely  laceration 
of  tissue.  Hernia  results,  in  almost  every  instance,  from  the 
gradual  stretching  of  tissue  and  escape  of  the  abdominal  con- 
tents, either  into  a  preformed  (congenital)  sac,  or  by  the 
formation  of  a  sac  (acquired)  from  the  peritoneal  lining  of 
the  abdomen. 

Abdominal  herni?e  derive  their  names  from  the  part  of 
the  abdominal  wall  through  which  they  pass.  The  terms 
mgumal,  femoral,  or  umbilical,  denote  at  once  their  place  of 

2  17 


18  ABDOMINAL  HERNIA. 

escape,  the  exception  to  this  being  ventral  hernia,  which  may- 
occur  at  any  point  in  the  anterior  abdominal  wah  other  than  in 
the  regions  named.  As  ventral  hernia  occurs  at  points  in  the 
muscular  wall  so  strong  as  ordinarily  to  resist  hernial  protru- 
sion, it  follows  that  when  it  does  occur,  it  is  either  due  to  some 
congenital  defect  or  is  the  result  of  some  injury,  such  as  a 
stab  wound  or  a  cutting  operation.  Extreme  distension  of  the 
abdomen  may  also  result  in  such  separation  of  its  aponeurotic 
fibres  as  to  allow  of  protrusion. 

A  little  more  than  73  per  cent,  of  all  hernias  are  of  the 
inguinal  type.  Next  in  frequency  is  femoral  hernia,  with  18 
per  cent.,  and  third,  umbilical  hernia  with  about  8^  per  cent. 
This  leaves. about  i  per  cent,  for  all  of  the  rarer  forms. 

The  individual  may  have  a  single  hernia  or  multiple 
hernise.  It  is  not  uncommon  to  find  inguinal  and  umbilical,  or 
inguinal  and  femoral  hernise  in  the  same  subject. 

The  type,  or  form,  of  hernia  is  notably  influenced  by  sex, 
as  shown  by  the  following  comparison : 

Male:  Inguinal,  96.33  per  cent.;  femoral,  2.53  per  cent.; 
umbilical,  1,14  per  cent. 

Female:  Inguinal,  50  per  cent.;  femoral,  33.15  per  cent.; 
umbilical,  15.9  per  cent. 

That  age  has  a  decided  influence  on  the  occurrence  of 
hernia  is  shown  by  the  exhaustive  studies  of  Paul  Berger.  His 
tables  show  19.6  cases  to  1,000  individuals  in  the  first  year  of 
life,  and  drops  to  4.2  per  1,000  in  the  second  year;  then  there 
is  a  gradual  decline  up  to  the  twentieth  year  when  only  0.88  is 
found.  From  this  time  on  to  the  seventy-fifth  year  the  in- 
crease of  proportion  is  constant,  reaching  at  this  age  its  highest 
point,  24.20  per  1,000  individuals. 

Hernia  consists  of  the  sac  and  its  contents;  the  sac  being 
formed  from  peritoneum,  the  lining  membrane  of  the  ab- 
dominal cavity.  It  may  be  formed  at  the  time  of  the  first  pro- 
trusion and  is  then  termed  an  acquired  sac.  As  will  be  demon- 
strated later,  a  congenital  sac  may  have  existed  long  before  the 
protrusion  of  the  hernia,  by  the  persistence  of  a  pouch  of 


INTRODUCTION.  19 

peritoneum  {Tunica  Vaginalis)  which  normally  should  have 
been  obliterated  at,  or  shortly  after,  birth. 

The  sac  consists  of  its  body,  or  the  expanded  portion, 
which  contains  the  bulk  of  the  protrusion ;  the  neck,  which  is 
the  constricted  part  running  through  the  muscular  wall ;  and  its 
mouth,  the  aperture  of  communication  with  the  peritpneal 
cavity. 

The  acquired  sac  on  first  protruding,  may  be  free  from 
adhesions,  and  reducible,  but  readily  becomes  attached  to  sur- 
rounding tissues  and  from  that  time  is  irreducible.  It  then  fur- 
nishes a  permanent,  moist,  serous  lining  to  the  canal  through 
which  it  protrudes. 

Hernia  of  the  bladder,  of  the  caecum  and  sigmoid  flexure, 
may  occur  without  a  true  hernial  sac.  The  anterior  bladder 
wall  is  not  covered  by  peritoneum,  and  it  may  form  the  actual 
protrusion  in  inguinal  hernia.  If  the  protrusion  is  of  fairly 
large  size,  it  will  also  drag  that  part  of  the  organ  into  the  canal 
that  is  covered  by  peritoneum,  when  both  bladder  and  ab- 
dominal contents  will  be  found.  This  same  condition  exists  in 
sigmoid  and  csecal  hernia,  except  that  in  these  the  peritoneum 
covers  the  anterior  wall  of  the  gut  and  the  posterior  wall  is 
dragged  down  without  this  covering. 

Following  previous  operations  where  the  peritoneum  has 
for  some  reason  failed  to  unite,  there  may  be  protrusion  imme- 
diately beneath  the  skin  without  sac  formation.  This  is  most 
frequently  met  with  in  ventral  hernia  following  laparotomy, 
but  I  have  found  in  one  instance  this  condition  existing  in  a 
recurrent  inguinal  hernia.  It  was  qtiite  evident  that  the 
previous  operator  had  either  failed  to  ligate  the  neck  of  the 
sac  properly,  or  what  is  more  likely,  the  ligature  had  slipped 
ofif,  and  both  omentum  and  intestine  were  in  contact  with 
scrotal  tissue. 

The  contents  of  a  sac  may  be  either  omentum,  intestine,  or 
in  fact  any  of  the  movable  contents  of  the  abdomen.  In  some 
rare  cases  even  those  organs  that  are  not  ordinarily  considered 
movable,   as   the  kidney   or  a  part   of   the   liver,   have  been 


20  ABDOMINAL  HERNIA. 

found  in  the  hernial  sac.  The  contents  of  a  sac  may  be  freely 
reducible,  or  its  reduction  may  be  prevented  by  the  great  size 
of  the  mass  and  the  smallness  of  the  neck  of  the  sac,  or  from 
adhesions  of  the  protruding  mass  to  the  inner  sides  of  the  sac; 
also  by  the  formation  of  fibrous  bands  which  transverse  the 
sac  in  different  directions. 

Omentum  and  small  intestine  are  most  frequently  found 
in  the  hernial  sac ;  next  in  frequency,  in  about  the  order  named, 
will  be  found  the  sigmoid  flexure,  csecum  and  transverse  colon. 
The  bladder  may  also  protrude  into  an  inguinal  hernia  sac,  but 
is  more  frequently  found  without  peritoneal  covering. 

The  term  enterocele  refers  to  hernia,  the  contents  of  which 
is  exclusively  intestine,  epiplocele  to  one  containing  omentum, 
and  the  use  of  the  words  combined,  as  entero-epiplocele,  to  one 
containing  both  intestine  and  omentum.  While  these  are  in 
some  instances  convenient  terms,  they  will  be  avoided  in  this 
work  on  the  ground  that  multiplicity  of  names  adds  to  the  con- 
fusion of  the  subject. 

SURGICAL  ANATOMY  OF  THE  INGUINAL 
REGION. 

The  lower  lateral  third  of  the  abdominal  wall,  known  as 
the  inguinal  region,  is  an  irregularly  shaped  triangle.  Roughly, 
its  outer  boundary  is  Poupart's  ligament,  its  inner  boundary 
the  median  line  of  the  body,  and  its  upper  boundary  an  im- 
aginary transverse  line  from  the  crest  of  the  ilium  to  the 
median  line.  The  anatomy  of  this  triangle,  although  the 
region  is  comparatively  small  and  easy  of  access,  has  proven 
one  of  the  most  difficult  to  comprehend  and  teach  of  any  con- 
nected with  the  muscular  system. 

The  author  assumes  that  his  reader  has  already  acquired 
an  anatomical  education  from  works  upon  the  subject  and  from 
practical  demonstration  upon  the  cadaver,  therefore,  the 
anatomy  here  given  is  merely  to  refresh  his  mental  picture  of 
the  parts.     If  the  picture  is  presented  from  a  different  view  to 


SURGICAL  ANATOMY. 


21 


that  which  he  is  accustomed,  and  minus  some  of  its  technical 
details,  it  may  be  even  clearer  in  outline,  in  which  case  the 
object  sought  will  have  been  fully  accomplished. 

Immediately  beneath  the  skin  of  this  region  we  come  upon 
the  two  layers  of  superficial  fascia.  These  layers  contain  a 
deposit  of  fat  of  variable  thickness  according  to  the  condition 


Fig. 


Showing  position  of  superficial  vessels  (size  exaggerated),  i,  Superficial  branch  of  ex- 
ternal pudic  artery.  2,  Superficial  epigastric  artery.  Both  are  in  deep  layer  of  superficial 
fascia  and  are  divided  in  hernia  operations.    3,  Circumflex  iliac  artery.    Not  usually  divided. 


of  the  patient.  In  operating  it  will  happen  many  times  that 
the  dividing  line  between  the  two  layers  is  not  discovered,  but 
occasionally  it  is  so  well  defined  as  to  mislead  the  operator 
into  the  belief  that  he  has  already  reached  the  aponeurosis  of 
the  external  oblique  muscle.  The  only  surgical  importance 
connected  with  this  fascia  is  that  the  deep  layer  contains  two 
sets  of  vessels  that  are  usually  cut  in  the  first  incision  in  hernia 
operations  (fig.  i). 


22 


ABDOMINAL  HERNIA. 


These  arteries  both  come  from  the  femoral  space  and  are 
first,  the  superficial  epigastric,  crossing  Poupart's  Hgament  at 
its  middle  third  and  passing  on  upwards  over  the  internal  ring 
towards  the  umbilicus.  Second,  a  superficial  branch  of  the 
external  pudic,  leaving  the  femoral  space  and  passing  up  di- 
rectly over  the  external  abdominal  ring,  and  arching  over  to 

Fig.  2. 


Aponeurosis  of  external  oblique  muscle,   in   which  is  shown  the  external   ring  covered  by 
the  intercolumnar  fascia. 

the  root  of  the  penis.     These  vessels  are  not  important  in  size 
but  may  require  ligation  at  time  of  operation. 

Beneath  this  fascia  we  find  the  aponeurosis  of  the  external 
oblique  muscle  which  is  easily  distinguished  by  'its  glistening 
surface  and  from  the  fact  that  its  fibres  run  obliquely  down- 
ward towards  the  public  bone  (fig.  2).  In  operations  for 
hernia  the  fleshy  part  of  the  external  oblique  muscle  is  seldom 


SURGICAL  ANATOMY.  23 

seen.  The  fibres  of  the  aponeurosis  are  bound  together  by  the 
overlying  intercolumnar  fascia,  which  is  tendonous  in  char- 
acter and  furnishes  strong  protection  to  the  upper  angle  of  the 
external  abdominal  ring,  by  arching  across  from  one  pillar  to 
another.  In  opening  down  to  the  external  abdominal  ring,  it 
frequently  obscures  the  upper  angle  of  that  aperture  and  pre- 
vents the  easy  passage  of  the  director  under  the  aponeurosis, 
until  it  has  been  scraped  away  with  some  blunt  instrument.  The 
cord  receives  this  fascia  as  its  last  covering  as  it  comes  out 
between  the  pillars  of  the  external  ring. 

The  aponeurosis  of  the  external  oblique  muscle  is  a  thin, 
but  very  tough,  inelastic  tendon,  which  splits  easily  in  the 
direction  of  the  fibres,  especially  after  the  intercolumnar  fascia 
is  cut,  but  furnishes  one  of  the  most  important  parts  of  the 
retaining  wall  of  the  abdomen.  At  its  lower  border  it  is  re- 
flected back  under  the  abdominal  wall  forming  Poiiparfs  liga- 
ment. This  lower  portion  of  the  aponeurosis  is  attached  to  the 
anterior  superior  iliac  spine  above,  and  to  the  spine  of  the  pubes 
below.  Just  above  the  pubic  attachment  there  is  a  split  in  the 
fibres  for  the  transmission  of  the  spermatic  cord  in  the  male 
and  round  ligament  in  the  female.  This  aperture  is  called  the 
external  abdominal  ring.  The  term  "  ring,"  an  unfortunate 
one,  conveys  the  idea  of  a  circular  opening,  wdien  in  reality  it 
is  triangular  in  shape.  This  name,  however,  has  from  long 
use  become  so  firmly  fixed  in  the  medical  mind  that  it  would 
probably  result  in  even  more  confusion  to  adopt  any  other. 
The  base  of  this  triangular  opening  is  formed  by  the  crest  of 
the  pubic  bone,  and  its  upper  angle  is  prevented  from  splitting 
still  higher  in  the  aponeurosis  by  the  intercolumnar  fascia.  The 
sides  of  the  triangle  are  formed  by  the  free  split  borders  of  the 
aponeurosis  and  are  called  the  pillars  of  the  ring.  The  ex- 
ternal, lower  pillar,  curves  around  in  sucli  a  manner  as  to  form 
a  groove  upon  which  the  cord  rests.  Tlie  infernal,  superior 
pillar,  passes  over  the  cord  to  the  crest  of  the  pubic  bone, 
to  interlace  in  the  median  line  with  its  fellow  of  the  opposite 
side.     On  account  of  the  cord  being  larger  than  the  round  liga- 


24 


ABDOMINAL  HERNIA 


ment,  and  to  the  fact  that  the  testicle  passes  down  through  this 
opening,  the  external  abdominal  ring  is  considerably  larger 
in  the  male  than  in  the  female. 

Poupart's  ligament,  extending  from  the  iliac  spine  to  the 
spine  of  the  pubes,  is  also  attached  to  the  pubic  bone  at  the 
pectineal  line  for  about  one  inch,  forming  Gimbernat's  liga- 


FlG.  3. 


Aponeurosis  opened   to   internal   ring,   showing  lower  border  of   internal  oblique  muscle; 
transversalis  fascia  in  deep  wall  of  canal. 

,  ment.  The  crural  arch,  beneath  which  emerges  the  femoral  ves- 
sels, is  formed  by  Poupart's  ligament,  internal  oblique  and 
transversalis  muscles  (figs.  3  and  4).  All  works  on  anatomy 
show  these  muscles,  as  shown  in  the  accompanying  cuts,  nicely 
dissected  one  from  the  other.  No  such  picture  is  presented  on 
the  operating  table  and  for  this  reason  the  two  muscles  will  be 
vSpoken  of  together.     The  lower  border  of  the  internal  oblique 


SURGICAL  ANATOMY.  2.3 

is  attached  to  the  outer  half  of  Poupart's  ligament,  and  the 
transversahs  is  attached  to  the  same  Hgament  immediately 
beneath  it,  but  (july  to  the  outer  third.  The  filjres  of  both 
muscles  are  fleshy  in  character  and  arch  up  over  the  cord,  the 


Fig.  4. 


A,  Symphysis  pubis.  B.  Anterior  superior  spinous  process  of  crest  of  ilium.  C, 
Muscular  part  of  external  oblique  muscle.  D,  Linea  alba.  .F,  J^,  External  abdominal 
rings.  /,  /,  Poupart's  ligament.  .V,  Aponeurosis  of  external  oblique  muscle  cut  open  to 
show  deeper  parts.  O,  Internal  oblique  muscle.  This  is  turned  up  at  lower  edge  to  show 
iP)  Transversalis  muscle.  (In  operative  work  these  muscles  are  seen  as  one.)  i^,  Trans- 
versalis  fascia.  R,  Internal  abdominal  ring.  S,  Epigastric  artery,  i,  i,  t.  Spermatic  cord. 
Oblique  inguinal  hernia  leaves  the  abdomen  at  /?,  (Internal  ring),  and  follows  the  cord  to 
F  (External  ring).  Direct  hernia  protrudes  directly  through  the  wall  at  F.  Femoral 
hernia  protrudes  at  IV.        (From  Sir  Astley  Cooper  on  Hernia.) 

transversalis  even  higher  than  the  internal  oblicjue,  and  then  the 
two  muscles  becoming  blended  into  an  aponeurotic  structure, 
the  conjoined  tendon,  pass  down  back  of  the  cord  and  find 
insertion  in  the  pectineal  line  of  the  os  pubis.     Here  conjoined 


26  ABDOMINAL  HERNIA. 

tendon  is  exactly  back  of  the  external  abdominal  ring,  and 
should  furnish  the  most  important  barrier  against  the  occur- 
rence of  direct  inguinal  hernia.  Some  of  the  fibres  pass  towards 
the  median  line  where  it  joins  its  fellow  of  the  opposite  side. 

The  lower  edges  of  these  muscles  are  indistinguishable  on 
the  operating  table,  and  are  treated  as  one  structure.  Normally, 
the  fibres  of  these  muscles  start  from  Poupart's  ligament  in 
front  of  the  cord,  and  arching  over  close  to  it,  descend  back 
of  the  cord  to  the  pubic  bone.  In  many  people  this  arch  is 
abnormally  high,  and  the  insertion  of  the  conjoined  tendon  is 
well  towards  the  median  line,  leaving  the  muscular  wall  back  of 
the  cord  very  deficient  throughout  the  whole  length  of  the 
inguinal  canal. 

At  the  time  of  descent  of  the  testicle,  through  the  canal, 
there  is  a  covering  taken  from  the  lower  edge  of  the  internal 
oblique  muscle  w4iich  develops  some  muscular  fibres,  and  is 
afterwards  known  as  the  crciuastcr  muscle.  This  fascia,  or 
muscle,  frequently  forms  one  of  the  coverings  of  a  hernial  sac. 
The  muscle  receives  its  blood  supply  from  the  cremasteric 
artery,  a  branch  of  the  epigastric,  and  its  nerve  supply  from 
the  genital  branch  of  the  genito-crural  nerve.  Neither  of  these 
are  ordinarily  seen  in  operations  for  hernia. 

When  the  aponeurosis  of  the  external  oblique  muscle  is 
first  split  and  retracted,  so  that  the  canal  is  freely  exposed,  the 
ilio-inguinal  nerve  will  usually  be  seen  following  closely 
the  lower  border  of  the  internal  oblique  muscle.  The  ilio-hypo- 
gastric  nerve  will  also  frequently  be  seen  a  little  higher  on  the 
surface  of  the  same  muscle. 

The  rectus  muscle  should,  perhaps,  be  mentioned  here  on 
account  of  its  relation  to  the  aponeuroses  of  the  muscles  just 
considered.  The  aponeuroses  of  all  of  the  abdominal  muscles 
below  the  umbilicus  pass  in  front  of  the  recti,  leaving  the 
posterior  surface  of  the  latter  in  contact  with  the  transversalis 
fascia.  The  muscle  is  attached  below  to  the  pubic  crest  as  far 
out  as  the  pubic  spine  and  doubtless  affords  some  protection  to 
the  external  abdominal  ringf. 


SURGICAL  ANATOMY.  27 

TRANSVERSALIS   FASCIA  OR  EXTRA  PERITONEAL  SHEATH. 

This  is  immediately  beneath  the  transversaHs  muscle  and 
while  in  the  upper  part  of  the  abdomen  it  is  thin,  in  the  inguinal 
region  it  is  thicker  and  stronger.  It  gives  the  cord  its  first 
covering,  the  infundihuliform  fascia.  It  also  forms  one  of  the 
coverings  of  oblique  inguinal  hernia. 

In  the  transversalis  fascia  is  situated  the  internal  ab- 
dominal ring.  This  is  a  purely  arbitrary  term  given  to  the 
beginning  of  the  inguinal  canal,  as  there  is  neither  a  ring  nor 
an  opening  into  the  abdominal  cavity  proper.  Immediately 
beneath  this  sheath,  or  fascia,  crossing  the  canal  at  right  angles 
just  below  the  internal  abdominal  ring,  is  the  deep  epigastric 
artery.  In  operations  for  hernia  this  important  vessel  is  fre- 
quently hidden  by  the  transversalis  fascia  and  its  location  must 
be  kept  constantly  in  mind  in  order  to  avoid  injury  to  it.  This 
vessel  and  its  accompanying  two  veins  are  embedded  in  the  sub- 
peritoneal areolar  tissue.  This  sheet  of  fat,  between  the  trans- 
versalis fascia  and  the  peritoneum,  is  of  variable  thickness  in 
different  individuals,  and  in  the  same  individual  at  different 
times.  It  is  very  abundant  in  the  vicinity  of  the  cord,  and  is 
frequently  an  important  factor  in  the  production  of  hernia  :  ( i ) 
In  its  liability  to  the  formation  of  lipomatous  tumors  which 
descend  through  the  canal,  dragging  a  process  of  peritoneum 
after  them.  (2)  During  violent  muscular  effort  this  fat  may 
be  forced  into  the  canal,  the  point  of  least  resistance,  where  it 
acts  as  a  dilating  wedge,  stretching  the  tissues  so  that  hernial 
protrusion  readily  follows.  Beneath  this  subperitoneal  fat  we 
have  the  peritoneum,  the  lining  membrane  of  the  cavitv  of  the 
abdomen.  Further  attention  will  be  given  this  important 
structure  when  we  have  finished  our  consideration  of  the 
abdominal  wall. 

Having  reviewed  briefly  the  structure  of  that  part  of  the 
abdominal  wall  involved  in  iguinal  hernia,  let  us  clearly  under- 
stand the  ingui)wl  canal  through  which  most  hernije  of  this 
region  descend.     \\'e  have  seen  that  the  transversalis  fascia 


28  ABDOMINAL  HERNIA. 

(or  extra  peritoneal  sheath),  where  it  envelops  the  cord  as  the 
infundibuliform  fascia,  is  really  the  internal  abdominal  ring 
and  the  beginning  of  the  canal.  From  this  point,  deep  in  the 
abdominal  wall,  the  canal  runs  parallel  with  Poupart's  ligament 
obliquely  towards  the  surface,  coming  out  beneath  the  skin 
through  the  split  in  the  external  oblique  known  as  the  external 
abdominal  ring.  At  birth  these  two  rings  are  almost  directly 
opposite  each  other,  but  on  reaching  adult  life  they  have 
become  separated  by  a  distance  of  about  one  inch  and  a  half. 
This  change  takes  place  rapidly  in  the  early  life  of  the  child. 

The  exact  boundaries  of  the  canal  are  somewhat  difficult 
to  understand,  as  in  some  instances  the  same  structures  form 
its  outer  boundary  high  up,  its  roof  lower  down,  and  its 
posterior  border  still  lower.  This  remark  applies  to  the  lower 
border  of  the  internal  oblique  and  transversalis  muscles.  Its 
boundaries  are  perhaps  better  understood  by  following  the 
steps  of  the  operator  rather  than  by  following  the  classical 
methods  of  the  dissector,  even  though  not  quite  as  accurate. 

After  division  of  the  skin  and  superficial  fascia,  and  split- 
ting the  aponeurosis  of  the  external  oblique  muscle  over  the 
whole  length  of  the  canal,  we  find  that  this  tendon  has  served 
as  the  principal  part  of  the  anterior  wall. 

Arching  over  the  cord,  in  front  of  the  internal  ring,  will 
be  found  muscular  fibres  belonging  to  the  internal  oblique  and 
transversalis  muscles.  For  a  distance  of  about  three-quarters 
of  an  inch,  from  the  internal  ring  down,  these  fleshy  fibres  form 
the  anterior  wall  of  the  canal,  the  remainder  of  the  distance 
being  formed  by  the  aponeurosis  of  the  external  oblique.  The 
roof  of  the  canal  is  principally  formed  by  the  lower  border  of 
the  internal  oblique  and  transversalis  muscles;  its  floor  by 
Poupart's  ligament. 

Its  posterior  boundary,  in  its  upper  two-thirds,  is  formed 
by  transversalis  fascia,  and  the  lower  third  by  the  conjoined 
tendon.  My  personal  experience  is,  that  in  by  far  the  greater 
number  of  cases  operated  upon  for  hernia,  nothing  is  found 
back  of  the  cord  but  transversalis  fascia  throughout  the  entire 


SURGICAL  ANATOMY.  29 

length  of  the  canal.  Beuealli  this  is  the  sub-peritoneal  fat  and 
the  peritoneum.  Embedded  in  the  sub-peritoneal  fat  are  the 
epigastric  vessels,  crossmg  the  posteri(jr  wall  of  the  canal  at 
right  angles  about  half  an  inch  below  the  internal  ring.  The 
inguinal  canal  is  occupied,  normally,  by  the  spermatic  cord  in 
the  male  and  the  round  ligament  in  the  female.  Tn  addition  to 
these  we  frequently  find  the  ilio-inguinal  nerve,  either  following 
the  surface  of  the  cord  or  along  the  lower  border  of  the  internal 
oblique  muscle. 

The  spermatic  cord,  as  it  passes  through  the  inguinal 
canal,  receives  the  following  coverings  :  ( i )  The  infundibuli- 
form  from  the  transversalis  fascia.  (2)  The  cremasteric  fascia 
(or  muscle)  from  the  internal  oblique.  (3)  The  inter- 
columnar  fascia  from  the  external  oblique,  as  it  passes  between 
the  pillars  of  the  external  abdominal  ring. 

DEEP     EPIGASTRIC     ARTERY. 

The  relation  of  the  deep  epigastric  artery  to  the  inguinal 
canal  is  important.  By  the  present  methods  of  operating  the 
artery  is  frequently  exposed  to  accident,  even  though  not 
always  seen.  It  lies  immediately  back  of  the  spermatic  cord 
between  the  transversalis  fascia  and  the  peritoneum,  and 
crosses  the  cord  at  an  oblique  angle  just  at  the  inner  and  lower 
border  of  the  internal  abdominal  ring.  It  passes  from  the 
external  iliac,  its  origin,  just  inside  of  Poupart's  ligament, 
obliquely  upwards  to  the  sheath  of  the  rectus  muscle.  It  is 
usually  accompanied  by  two  veins.  The  close  relation  of  the 
external  iliac  artery  to  the  parts  under  consideration  must 
always  be  borne  in  mind  (see  fig.  5).  Although  it  is 
within  the  abdominal  cavity,  it  is  frequently  in  contact  witli  the 
deep  parts  of  the  canal,  and  several  accidents  to  this  vessel 
during  operations  are  knowm  to  me,  and  one  has  been  pub- 
lished by  an  eminent  operator.  The  other  blood  vessels  of  this 
region,  outside  of  those  forming  the  spermatic  cord,  are  unim- 
portant from  a  surgical  standpoint. 


30 


ABDOMINAL  HERNIA. 


The  nerje  supply  to  this  region  is  by  the  ilio-hypo gastric 
and  ilio-ingiiinal  from  the  upper  hmibar  nerves,  and  is  purely- 
sensory  in  character.  These  nerves  are  frequently  seen  when 
operating,  just  below  the  aponeurosis  of  the  external  oblique. 


Fig.  5. 


To  illustrate  proximity  of  deep  epigastric  and  iliac  arteries  to  inguinal  canal. 

and  with  a  little  care  can  be  avoided,  but  their  division 
is  only  attended  by  temporary  loss  of  sensation  over  a  small 
area  of  surface. 

Peritoneum. — We  have  constantly  to  deal  with  this  struc- 
ture in  hernia  operations,  as  all  hernial  sacs  are  formed  from 


SURGICAL  ANATOMY.  31 

It,  and  it  rarely  happens  tliat  abdominal  hernia  occurs  without 
peritoneal  covering  which  becomes  its  sac. 

This  serous  membrane  not  only  completely  lines  the 
abdomen,  but  entirely  or  partially  envelopes  every  hollow  organ 
contained  in  this  cavity.  Its  surface  is  normally  moist  and 
shiny.  It  wraps  itself  completely  about  the  small  intestine  and 
passes  backwards  to  the  spine,  where  it  is  attached  as  the 
mesentery.  The  mesentery  gives  to  the  intestine  at  least 
partial  support;  in  hernial  protrusions,  however,  it  may  bec(jme 
not  only  enormously  elongated,  but  so  changed  in  character  as 
seriously  to  interfere  with  operative  procedures.  The  right 
segment  of  the  mesentery  is  longer  than  the  left,  allowing  of 
greater  pressure  from  the  intestine  in  the  right  hypogastric 
fossae.  This  may,  in  a  measure,  explain  the  greater  number  of 
hernise  on  the  right  side.  The  external  inguinal  fossa  is  at  the 
outer  side  of  the  epigastric  artery  and  immediately  back  of  the 
internal  ring.  This  is  the  deepest  of  the  fossae,  and  that  on 
the  right  is  deeper  than  the  one  on  the  left,  another  reason  for 
the  more  frequent  occurrence  of  inguinal  hernia  on  the  right 
side.  Hernias  entering  the  external  inguinal  fossa  and  passing 
into  the  canal  become  oblique  inguinal  hernia. 

The  fossa  towards  the  median  line  from  the  epigastric 
artery,  is  the  internal  hypogastric  fossa,  and  it  is  in  this  pocket 
that  direct  inguinal  hernia  originates.  In  the  relation  of  the 
protrusion  of  hernia  to  the  epigastric  artery  originated  the 
terms,  external  and  internal  inguinal  hernia,  the  protrusion 
into  the  external  fossa  (oblique)  being  termed  external,  and  that 
into  the  internal  fossa  (direct)  internal  hernia.  The  author  has 
for  many  years  avoided  using  these  terms  in  his  teaching,  as 
they  are  confusing  and  misleading.  Internal  herniie  are  be- 
lieved to  be  such  as  occur  within  the  body,  as  hernia  through 
the  diaphragm  into  the  chest  cavity,  or  hernia  through  the 
foramen  of  Winslow. 

While  any  organ  within  the  abdominal  cavity  may  become 
involved  in  hernia,  there  is  only  one  other  structure  that  we 
shall  consider  in  this  part  of  the  work,  and  that  is  the  onienfuni. 


32 


ABDOMINAL  HERNIA. 


This  forms  a  ratlier  constant  factor  in  the  diagnosis  and  treat- 
ment of  hernia  (fig.  6). 

The  omentum  hangs  as  a  great,  fatty  apron  between  the 
abdominal  contents  and  anterior  muscular  wall,  doubtless  form- 
ing an  important  means  of  protection  tO'  the  bowels  from 
sudden  changes  of  temperature,  and  against  injury  from  blows 


Fig.  6. 


The  greater  omentum  as  seen  from  the  front. 

Upon  the  abdominal  surface.  To  those  suffering  from  hernia, 
it  is  the  source  of  much  trouble,  and  necessarily  much  will  be 
said  about  it  in  the  pages  to  follow. 

It  hangs  in  two  sheets,  or  la3^ers,  each  covered  by  peri- 
toneum, from  the  lower  convex  border  of  the  stomach  and 
from  the  transverse  colon.  Perhaps  it  would  convey  a  clearer 
idea  to  say  that  it  passes  down  to  the  pelvis  from  its  attach- 


SURGICAL  ANATOMY.  S.'} 

ment  to  the  stomach,  is  tohlcd  upon  itself,  and  returns  hj  the 
transverse  colon.  1"hc  space  between  is  normally  a  shut  sac, 
but  frecjuenlly,  owinji;-  to  the  delicate  structure  of  the  omentum, 
opening's  into  it  will  be  found.  Intestinal  obstruction  is  some- 
times due  to  constriction  of  a  locjp  oi  bowel  in  such  an  opening. 
The  two  layers  cannot  always  be  distinguished ;  in  fact,  they 
seldom  are  when  dealing  with  its  lower  part,  but  it  must  be 
remembered  that  they  exist,  as  it  not  only  hap])cns  that  cysts 
may  form  between  these  layers,  but  intestine  has  slipped  in 
between  them,  and  in  this  position  has  been  ligated  with  the 
omentum  and  actually  cut  away. 

The  nerve  supply  to  the  omentum  is  poor,  but  its  blo(jd 
vessels  are  large  and  numerous.  These  vessels  have  very  deli- 
cate w'alls,  and  as  they  are  not  surrounded  by  muscular  fibre, 
there  is  no  tendency  to  contract.  A  bleeding  vein  that  perhaps 
would  be  of  no  importance  elsewhere,  in  this  structure  might 
easily  cause  fatal  hccmorrhage. 

When  omentum  first  protrudes  in  hernia  it  has  all  of  its 
normal  characteristics,  but  if  allowed  to  protrude  frequently, 
or  remain  in  the  hernial  sac,  it  becomes  hypertrophied,  in- 
durated, nodular,  and  may  then  at  times  act  as  a  foreign  body 
if  returned  to  the  abdominal  cavity.  It  no  longer  belongs 
within  that  cavity.  Omentum  allowed  to  lie  in  the  hernial  sac 
soon  becomes  adherent  to  its  sides  and  forms  the  most  com- 
mon type  of  irreducible  hernia. 


CHAPTER  II. 

DESCENT   OF  THE  TESTICLE. 

A  knowledge  of  the  formation  and  descent  of  the  testicle 
affords  an  insight  into  the  cause  and  origin  of  many  hernise, 
especially  in  those  that  occur  in  early  life,  and  it  has  direct 
bearing  upon  some  of  the  complications  which  may  arise  during 
treatment.  It  is  important,  therefore,  that  we  give  this  process 
careful  consideration. 

The  genital  mass  which  is  primarily  formed  just  below  the 
kidney  and  behind  the  peritoneum,  begins  its  transit  towards  the 
pelvis,  before  it  can  be  definitely  stated  whether  it  is  to  become 
ovary  or  testis.  In  the  male  this  transition  is  not  complete 
until  it  has  passed  through  the  abdominal  wall  to  its  natural 
abiding  place  in  the  scrotum.  In  the  female  the  descent  of  the 
genital  body  is  normally  to  the  pelvic  cavity,  where  it  remains 
as  the  ovary.  The  analogy  between  the  sexes  is  sometimes 
carried  farther  by  the  persistent  effort  of  an  ovary  to  descend 
into  the  labium  majora. 

It  has  occurred  several  times  in  my  experience  that  the 
ovary  in  its  descent  has  followed  the  ordinary  course  of  the 
testicle,  and  has  been  found  outside  the  external  ring,  in  which 
position  it  is,  in  some  instances,  irreducible.  Another  notice- 
able fact  is,  that  when  the  ovary  has  once  entered  the  canal, 
it  is  almost  as  persistent  in  its  effort  to  descend  through  it,  as 
the  testicle  is  under  the  same  circumstances.  Like  the  testicle, 
the  ovary  may  become  adherent,  or,  from  other  causes,  lodge 
at  any  point  in  the  canal  and  not  pass  entirely  outside  the 
abdominal  wall.  It  may  then  lead  to  difificult  and  painful 
menstruation,  to  the  formation  of  cysts,  or,  as  found  in  one 
case,  such  degeneration  of  its  structure  as  to  require  removal. 

In  the  elephant  and  some  other  animals,  the  testicles  re- 
main permanently  in  the  abdomen,  while  tlie  stallion,  in  some 
instances,  has  them  under  voluntary  control,  so  that  they  may 

34 


DESCENT  OF  THE  TESTICLE. 


35 


be  found  either  within  the  abdomen  or  in  the  scrotum.  In 
some  other  animals,  they  descend  at  the  "  rutting  "  season 
only.  Instances  where  they  are  wholly,  or  partially,  retained 
within  the  abdomen  in  the  human  subject  are  not  uncommon. 
Where,  however,  they  descend  late  in  life  or  at  any  time  after 
birth,  they  are  quite  certain  to  leave  the  inguinal  canal  in 
such  a  weakened  state,  that  hernial  protrusions  are  liable  to  fol- 
low. The  testicle,  in  passing  through  the  muscular  wall  of  the 
abdomen,  carries  with  it  the  various  layers  of  fascia  which 


i^IG.  7. 


A  left  testis  retained  in  the  cruro-scrotal  fold.— A,  Testis.     B,  Fasciculus  of  gubernaculuin 
attached  to  scrotal  tissue  at  C.    {Godard,  from  Eccles'  "  Imperfectly  Descended  Testicle.'") 


form  the  sheath  of  the  cord ;  these  fascial  layers  are  only 
demonstrated  by  the  most  minute  dissection,  and  are  unim- 
portant in  the  present  consideration  of  the  subject. 

TJie  gnbernaculum  testis  is  a  bundle  of  fascia  containing 
muscular  fibres,  which  are  attached  to  the  testicle  at  one  end- 
and  in  the  scrotum  at  the  other.  At  its  lower  end  a  few  fibres 
pass  off  towards  the  thigh  and  some  go  to  the  perineum.  It  is 
these  fibres  outside  the  scrotum  that  are  believed  to  be  active  in 
guiding  the  testicle  into  abnormal  positions  in  some  instances. 
The  action  of  the  gnbernaculum  testis  is  not  perfecly  under- 


36 


ABDOMINAL  HERNIA. 


stood,  and  it  is  not  well  known  whether  it  aids  in  the  descent 
of  the  testicle  by  a  contractile  force,  or  merely  serves  as  a 
guide  in  a  process  that  is  carried  out  by  some  other  method 
of  development. 

The    accompanying   illustrations    (Eccles)    clearly    illus- 
trate two  distinct  types;  one  (fig.  7)  showing  the  testicle  just 


Fig,  8. 


A  left  testis  lying  in  the  perineum. — The  testis  was  the  size  of  an  almond,  and  its  compo- 
nent parts  could  be  readily  made  out  through  the  skin.  The  left  half  of  the  scrotum  was 
undeveloped.  The  right  testis  was  of  normal  size  in  the  right  half  of  the  scrotum.  (Godard 
from  Eccles'  "  Imperfectly  Descended  Testicle.") 

outside  of  the  abdominal  wall  with  the  overlying  tissues  turned 
back.  It  also  graphically  shows  the  action  of  the  gubernac- 
ulum  testis  upon  the  scrotal  wall.  The  other  illustration  (fig. 
8)  shows  a  small  testicle  lodged  in  the  perineum,  and  the 
scrotum  on  the  left  side  undeveloped.  Dr.  W,  B.  Coley  has 
called  the  hernia  that  sometimes  develops  with  this  form 
of  mal-descent  "inguino-perineal  hernia."     Still  another  posi- 


DESCENT  OF  THE  TESTICLE. 


37 


tion  is  shown  in  fig".  9,  where  the  testicle  has  descended  into 
the  tissues  gf  the  thigh,  presenting  in  Scarpa's  triang-le  the 
appearance  of  femoral  hernia.  Fig-.  10  shows  a  testicle  lodged 
just  outside  the  external  abdominal  ring,  with  hernia  in  the 


inguinal  canal. ^ 


Fig.  9. 


A  left  testis  in  Scarpa's  triangle.      Its  cord  could   be  traced  through   the  superficial 
abdominal  ring.     {Eccles.) 

The  descent  of  the  testicle  may  be  arrested  at  any  point 
within  the  abdomen,  or  it  may  pass  into  the  iliac  fossa  and 
remain  there.  It  may  lodge  at  any  point  in  the  inguinal  canal 
between  the  internal  and  external  rings,  or  it  may  pass  on  to  a 
wholly  abnormal  position  outside  the  scrotum  and  be  found  in 
the  perineum,  at  the  root  of  the  penis,  or  into  the  subcutaneous 

'  Dr.  Albert  E.  Halstead  of  Chicago  reports  a  case  where  both  testicles 
were  found  on  oiie  side  of  the  scrotum.  Ectopia  Testis  Transversa,  Sur- 
gery Gynecology  and  Obstetrics,  p.  129,  February,  1907. 


38 


ABDOMINAL  HERNIA. 


tissues  of  the  upper  part  of  the  thigh.  At  times,  it  comes  out 
of  the  external  ring,  but  turns  upwards  upon  the  surface  of  the 
aponeurosis  of  the  external  oblique  muscle  towards  the  crest 
of  the  ilium.  Its  normal  descent  may  be  prevented  by  a 
deficiency  in  the  attachment,  or  formation,  of  the  gubernaculum 
testis,  by  adhesions,  or  by  lack  of  development  of  the  inguinal 
canal.     The   external   abdominal   ring  may   be   too   small   to 

Fig.  io. 


Right  testicle  in  canal  at  external  ring.    Complete  oblique  inguinal  hernia  above  it.     Left 
testicle  at  internal  ring.    Scrotum  rudimentary. 


allow  it  to  pass,  or  the  scrotum  may  be  so  undeveloped  as  to 
prevent  its  entrance.  It  may  even  be  retarded  and  its  descent 
prevented  by  a  truss  improperly  applied  for  associated  hernia. 
There  is  considerable  difference  of  opinion  as  to  whether 
a  testicle  which  has  been  prevented  from  reaching  its  normal 
position,  is  functionless,  and  the  preponderance  of  evidence 
would  seem  to  indicate  that  in  a  large  number  of  cases  it  is. 
This  has  led  eminent  authorities  to  advise  their  removal  at  the 


DESCENT  OF  THE  TESTICLE.  39 

time  of  operation.  Recent  studies  prtjve  beyond  question,  how- 
ever, that  there  is  an  internal  secretion  from  these  functionless 
testicles,  which  is  markedly  beneficial  to  the  proper  develop- 
ment of  the  individual,  especially  at  the  period  of  chani^e  from 
youth  to  adult  life.  It  is,  therefore,  very  desirable  that  they 
should  be  preserxed  in  e\ery  instance,  unless  their  diseased 
condition  should  proxe  a  menace  to  the  health  of  their  pos- 
sessor. 

In  view  of  the  considerations  just  stated  and  the  mental 
effects  of  castration,  an  operation  will  be  detailed  under  its 
proper  heading,  which  enables  us  to  leave  these  testicles  under 
the  muscular  wall  of  the  abdomen,  in  cases  where  the  cord  is  so 
short  as  to  make  it  impossible  to  place  them  in  the  scrotum. 

TUNICA    \-AGIXALIS. 

Previous  to  the  descent  of  the  testicle,  and  apparently 
not  dependent  upon  the  transit  of  that  organ,  a  pouch  of  peri- 
toneum, subsequently  known  as  the  tunica  vaginalis,  descends 
into  the  scrotum.  The  neck  of  this  pouch,  which  communi- 
cates with  the  cavity  of  the  abdomen,  should  be  obliterated  at 
birth,  leaving  that  part  which  is  anterior  to  the  testicle  a  closed 
sac,  the  cavity  of  the  tunica  vaginalis.  Failure  to  complete  the 
obliteration  of  the  neck  of  communication  between  these 
cavities,  leads  to  the  formation  of  certain  types  of  herniae, 
and  produces  several  forms  of  complications. 

This  process  of  peritoneum  should  be  obliterated  at  birth, 
or  in  early  infancy,  but  for  unexplained  reasons  it  sometimes 
continues  patulous  until  adult  life.  It  is  the  remaining  open, 
or  the  dilating  of  the  partially  closed  neck  of  this  pouch,  that 
alloW'S  congenital  hernia  to  pass  down  in  front  of  the  testicle, 
wdthout  true  peritoneal  covering.  The  normal  obliteration  of 
the  neck  of  this  process  begins  by  three  points  of  closure. 
These,  it  is  well  to  remember,  have  special  bearing  upon  cvstic 
formations,  which  occur  between  them  bef(^re  complete  oblitera- 
tion has  taken  place.     They  are  at  the  deep  abdominal  open- 


40 


ABDOMINAL  HERNIA. 


ing,  at  the  sui^eriicial  abdominal  opening,  and  immediately 
above  the  testicle.  That  portion  which  lies  immediately  in 
front  of  the  testicle  forms  the  cavity  of  the  tunica  vaginalis, 
where  hydrocele  of  this  membrane  may  occur. 

The  word  ''  congenital.''  as  applied  to  that  type  of  hernia 
which  protrudes  into  this  cavity,  has  been  and  is  confusing.  It 
places,  by  inference,  the  date  of  origin  of  the  hernia  at  the  birth 
of  a  child,  whereas,  as  a  matter  of  fact,  congenital  hernia  may 


Fig.  II. 


A,  A,  A,  Cysts  in  front  of  cord.    B,  Cyst  hanging  within  abdomen  by  pedicle  three  inches 
long.     C,  Cord.    D,  Testicle. 

occur  at  almost  any  period  of  life,  in  subjects  where  the  process 
of  obliteration  of  the  neck  of  this  cavity  has  never  taken  place. 
It  is  only  in  recent  years  that  anatomists  have  ascertained  that 
in  many  subjects,  in  whom  hernia  has  never  occurred,  there 
remains  a  small  opening  between  the  cavity  of  the  abdomen 
and  the  cavity  of  the  tunica  vaginalis  throughout  life.  The 
term  congenital,  therefore,  refers  to  a  defect  which  was 
present  at  birth,  and  which  predisposes  to  a  certain  type  of 
hernia. 


DESCENT  OF  THE  TESTICLE. 


41 


The  drawing  shown  in  fig.  1 1  has  been  made  from  one  of 
a  number  of  similar  cases  met  with  in  operative  work.  It  is 
intro(kiced  to  ilhistrate  how  cysts,  forming  in  tlie  partially 
obliterated  tunica  vaginalis,  may  prove  confusing  in  diagnosis 
and   troublesome    during   operation.     A    young   man,    of    24 

Fig.  12. 


Hydrocele  of  cord  simulating  irreducible  hernia.  Dotted  line  shows  tumor  extending- 
to  the  internal  ring.  Notice  separation  between  tumor  and  testicle,  showing  that  tunica 
vaginalis  proper  is  not  involved.     Entire  cyst  removed  by  operation. 

years,  had  experienced  much  trouble  in  wearing  a  truss,  and 
upon  examination  it  was  decided  that  a  part  of  his  hernia  was 
irreducible.  Upon  operating,  a  sac  about  three  inches  long 
was  found,  and  back  of  this  were  three  cysts,  shown  in  the 
sketch,  closely  associated  with  the  cord.  Within  the  neck  of 
the  sac  was  noticed  a  cord-like  attachment  which,  when  drawn 


42  ABDOMINAL  HERNIA. 

upon,  brought  from  the  abdominal  cavity  a  cyst  the  size  and 
shape  of  a  small  pear,  hanging  in  the  abdomen  by  a  pedicle 
fully  ^hree  inches  long. 

There  is  little  doubt  that  all  of  these  cysts  formed  in 
imobliterated  portions  of  the  tunica  vaginalis,  and  at  the  upper 
portion  of  the  canal,  had  bulged  forward  into  the  forming 
hernial  sac,  and  finally  dropped  back  into  the  peritoneal  cavity. 
This  occurrence  was  undoubtedly  aided  by  the  truss  which  had 
been  worn  over  the  canal  lower  down. 

Fig.  12  shows  a  young  man  with  hydrocele  of  the  cord, 
extending  from  the  top  of  the  testicle  to  the  internal  ring.  He 
was  subsequently  operated  upon,  the  entire  cyst  removed,  and 
the  canal  closed  by  the  Bassini  method. 

CANAL     OF     NUCK. 

The  process  of  peritoneum  under  consideration,  enters  the 
canal  of  the  female  fetus  the  same  as  in  the  male,  and  while 
ordinarily  obliterated  at  birth,  it  may  persist,  producing  similar 
conditions  and  complications. 

Nuck,  in  the  seventeenth  century,  recognized  this  condi- 
tion, and  when  present  it  bears  his  name. 

When  it  remains  patulous,  it  allows  of  the  occurrence  of 
congenital  hernia  in  the  female,  or  of  congenital  (reducible) 
hydrocele.  Its  presence  also  accounts  for  encysted  hydrocele 
in  the  canal  of  the  female,  not  uncommonly  met  with  in  opera- 
tive W'ork.  It  may  be  coincident  with  hernia,  or  exist  alone, 
and  I  have  long  felt  that  it  accounts  for  some  failures  to  cure 
the  female  infant  by  truss  treatment. 

SPERMATIC     CORD. 

The  cord  extends  from  the  internal  abdominal  ring 
through  the  canal  to  the  testicle,  and  is  composed  of  the  vas 
deferens,  three  arteries  with  their  return  veins,  lymphatics,  and 
nerves,  lliese  vessels  are  held  together  and  the  cord  formed 
by  its  sheath,  which  is  composed  of  three  layers  of  fascia  given 


DESCENT  OF  THE  TESTICLE.  43 

off  from  tlie  edges  of  the  abdominal  muscles  as  the  cord  fcjliows 
the  testicle  in  its  descent.  These  are  from  the  deepest  towards 
the  surface:  (i)  Infundibuliform  fascia.  (2)  Cremasteric 
fascia.  (3)  Intercolumnar  ( or  spermatic )  fascia.  The  cre- 
masteric fascia,  or  muscle,  as  it  is  frecj[uently  called,  contains 
muscular  fibre  as  well  as  fibrous  tissue,  and  aids  in  the  support 
of  the  testicle.  In  some  children  and  young  persons,  this 
muscle  acts  so  violently  at  times,  as  to  draw  the  testicle  against 
the  external  abdominal  ring  with  such  force  as  to  cause  consid- 
erable pain.  This  action  will  be  referred  to  again  in  connection 
with  diagnosis,  as  "  Retraction  of  the  Testicle."  Except 
the  cremaster  these  fasci?e  are  seldom  demonstrable  at  the  time 
of  operation. 

The  nerve  supply  to  the  cord  is  from  the  renal  plexus  and 
by  the  genital  branch  of  the  genito-crural.  To  the  latter  is  due 
the  "  cremasteric  reflex  "  noticeable  in  many  boys  on  touching 
suddenly  the  inner  surface  of  the  thigh,  that  surface  being  sup- 
plied by  another  branch  of  the  same  nerve. 

The  vas  deferens,  or  excreton,-  duct,  lies  at  the  inner  side 
of  the  cord,  especially  at  the  upper  part  of  the  canal,  and  turns 
sharply  at  the  internal  ring  to  go  to  the  base  of  the  bladder, 
while  the  vessels  continue  on  their  course.  This  separation 
accounts  for  the  fact,  that  in  the  protrusion  of  hernia  the  vas 
deferens  may  be  on  one  side  of  the  sac,  while  the  vessels  are 
on  the  other.  In  hernia  the  usual  position  of  the  cord  is  back 
of  the  sac,  but  it  is  frecjuently  found  in  front  of,  or  at  either 
side  of  it. 


CHAPTER  III. 

CAUSE   OF   INGUINAL   HERNIA. 

Inguinal  hernia  forms  about  three-fourths  of  all  herniae, 
and  should  therefore  have  most  careful  consideration.  Its 
causes  naturally  arrange  themselves  into  two  groups ;  those  that 
are  predisposing,  and  those  that  are  immediate,  or  direct. 

PREDISPOSING    CAUSES. 

The  following  list  of  predisposing  causes  of  inguinal 
hernia  has  been  compiled  for  use  in  this  work  :  ( i )  Heredity ; 
(2)  Age;  (3)  Sex;  (4)  Descent  of  processus  vaginalis  (male 
and  female)  ;  (5)  Descent  of  testicle;  (6)  Anatomical  defects; 
(7)  Fat,  excess,  or  sudden  increase  of. 

I.  Heredity. — The  result  of  the  study  of  inheritance  as  a 
predisposing  cause  of  hernia  has  not  been  very  satisfactory,  as 
it  has  proven  little;  but  it  has  been  strongly  urged  by  some 
authors  and  doubted  by  others.  The  subject  is  attended  by  too 
many  uncertainties  and  too  many  statistics  to  receive  extended 
consideration  in  this  work.  While  in  my  own  experience  I 
have  had  some  striking  indications  that  the  tendency  to  hernia 
is  occasionally  transmitted  from  one  generation  to  another,  I 
have  arrived  at  no  conclusion  as  to  what  that  tendency  may 
consist  of. 

Sir  Astley  Cooper  attempted  over  a  century  ago  to  show 
that  it  was  due  to  the  shape  of  the  bony  pelvis,  and  others  have 
attributed  it  to  an  inherited  laxness  of  muscle,  which  proves 
inefficient  in  the  retention  of  the  abdominal  contents.  The 
theory  of  an  inherited  weakness  of  the  abdominal  muscles  ap- 
peals to  me,  and  appears  to  be  sustained  by  experience.  In  one 
family,  the  members  of  which  have  been  under  my  care  for 
twenty-five  years,  three  different  generations  have  been  cared 
for,  and  the  three  principal  forms  of  abdominal  hernia   (in- 

44 


CAUSE  OF  INGUINAL  HERNIA.  45 

guinal,  femoral,  and  umbilical)  have  been  represented  in  their 
ordinary  proportion.  The  cases  are  largely  among  the  female 
members  of  the  family,  who  have  every  appearance  of  good 
health  and  strong  muscles.  No  member  of  this  family  would 
consent  to  operation,  so  that  opportunity  has  not  been  afforded 
to  confirm  the  belief  that  muscular  deficiency  is  the  cause  of 
the  inheritance. 

2.  Age. — The  extremes  of  life  are  undoubtedly  more 
productive  of  hernia  than  the  intervening  period,  and  for  dis- 
cernible reasons.  In  early  infancy  we  have  not  only  the  short 
canal,  the  internal  ring  being  directly  back  of  the  external  ring 
at  birth,  but  we  have  the  defects  due  to  mal-descent  of  the 
testicle  and  lack  of  obliteration  of  the  tunica  vaginalis. 

Lockw^ood  ^  has  also  demonstrated  that  in  early  life  the 
mesentery  is  longer  than  in  the  years  of  maturity,  being  one- 
fifth  the  length  of  the  body.  At  forty  years  of  age  it  is  only 
one-ninth  the  length  of  the  body.  In  old  age  we  have  the 
degeneration  of  tissue  so  common  to  advancing  years,  and  the 
change  in  form  well  shown  in  fig.  13,  ^vhen  the- stooping  for- 
ward and  relaxation  of  the  abdominal  muscles  places  them  at 
great  disadvantage.  It  has  been  stated  that  this  form  of 
abdomen  is  the  result  of  large  hernise,  but  to  my  mind  it  is 
more  frequently  a  cause  of  hernia. 

3.  Sex, — The  influence  of  sex  upon  the  incidence  of  in- 
guinal hernia,  is  clearly  shown  by  the  large  preponderance  of 
this  type  of  hernia  among  males.  This  difference  is  probably 
due  to  the  large  size  of  the  spermatic  cord  as  compared  with 
the  round  ligament  in  the  female,  to  the  descent  of  the  testicle 
through  the  inguinal  canal,  and  its  lodgements  and  detentions. 
The  descent  of  the  tunica  vaginalis  also  plays  an  important 
part  in  the  increase  of  hernise  among  males.  It  is  true  that 
this  same  process  occupies  the  canal  of  the  female,  and.  as  the 
canal  of  Nuck,  aids  in  the  production  of  hernia,  but  not  to  the 
same  extent  as  in  the  male. 

^  Pathology   and  Treatment  of  Hernia.     C.   B.   Lockwood,    F.R.C.S., 
London,   1889. 


46 


ABDOMINAL  HERNIA. 


4.  Descent  of  Tunica  Vaginalis. — The  failure  of  complete 
obliteration  of  the  connecting  neck,  between  the  cavity  of  the 
tunica  vaginalis  and  the  cavity  of  the  abdomen,  beyond  doubt 
leads  to  the  formation  of  many  inguinal  hernise.  This  open- 
ing may  exist  for  years  without  the  protrusion  of  hernia,  but 
usually,  where  it  is  present,  it  only  needs  unusual  strain  to 
fill  the  already  formed  sac. 

Fig.  13. 


Side  view  of  the  abdomen  of  an  old  man  with  scrotal  hernia.     To  show 
the  flattening  above  the  umbilicus.     (Macready.) 


5,  Descent  of  the  Testicle. — The  formation  and  descent  of 
the  testicle,  through  the  alidominal  \vall,  is  l^elieved  to  have 
such  an  im])ortant  place  in  the  procUiction  of  inguinal  hernia,  in 
the  male,  that  this  transit  has  already  been  carefully  considered 
in  the  chapter  devoted  to  this  subject. 

6.  Anatomical  Defects. — There  are  certain  anatomical  de- 
fects in  the  muscular  formation,  about  tlie  inguinal  canal,  which 


CAUSE  OF  INGUINAL  HERNIA.  47 

unquestionably  lead  to  a  very  large  number  of  herniae,  yet  they 
have  not  attracted  specific  attention  until  recent  years,  when 
frequent  operations  ha\e  demonstrated  them  to  every  extensive 
operator  upon  iiernia. 

The  lower  borders  of  the  internal  oblicjue  and  transversalis 
muscles,  passing  over  the  cord  as  the  latter  enters  the  canal 
at  the  internal  ring,  run  parallel  with  it  and  find  inserti(jn  into 
the  pubic  bone.  In  front,  the  canal  is  protected  by  a  dense, 
fibrous  layer,  the  aponeurosis  of  the  external  oblique  muscle, 
but  back  of  the  cord  there  is  little  protection  against  protrusion, 
except  that  afforded  by  the  peritoneum  and  the  fascia  trans- 
versalis. This  muscular  defect  allows  of  deep  pocketing  from 
the  peritoneal  surface  into  the  hypogastric  fossa,  and  consti- 
tutes a  strong  predisposing  cause  of  hernia.  In  the  older  oper- 
ations this  weakness  was  not  considered,  and  all  repair  work 
was  done  at  the  external  ring,  leaving  the  original  defect  to 
invite  a  recurrence  of  hernia. 

Another  anatomical  defect  which  is  a  frequent  cause  of 
hernia,  especial jy  in  early  life,  is  the  nonobliteration  of  the  com- 
municating neck,  between  the  cavity  of  the  tunica  vaginalis 
and  the  cavity  of  the  abdomen.  That  portion  of  the  pouch 
of  peritoneum  which  descends  in  front  of  the  testicle,  be- 
coming the  tunica  vaginalis,  should  be  closed  off  from  the 
abdomen  by  the  obliteration  of  its  neck,  which  passes  through 
the  inguinal  canal.  This  stage  of  development  should  have 
been  reached  at,  or  before,  birth,  but  unfortunately  it  fails  to 
occur  in  a  large  number  of  persons,  and  the  peritoneal  surface 
remains  continuous  down  into  this  pouch  in  the  scrotum,  invit- 
ing a  protrusion  through  the  moist,  tube-like  opening. 

Probably  numerous  persons  have  this  condition  through- 
out life  without  developing  hernia,  but  in  many  others  it  is  an 
important  predisposing  cause.  When  a  hernia  occurs  in  this 
pouch,  it  is  known  as  congenital  hernia;  the  term  not  mean- 
ing that  hernia  was  necessarily  present  at  birth,  but  that  the 
defect  was,  which  led  to  its  occurrence.  \Ve  see  numerous 
cases  of  congenital  hernia  occurring  at  all  ages  up  to  adult  life. 


48 


ABDOMINAL  HERNIA. 


showing  that  this  tubular  neck  of  communication,  between  the 
two  cavities,  has  persisted  during  all  of  the  previous  years  that 
the  patient  has  lived,  and  needed  only  some  additional  cause  to 
produce  the  hernia. 

The  two  anatomical  peculiarities  named  are  considered  by 
far  the  strongest  predisposing  causes,  the  first  existing  to  a 

Fig.  14. 


Abdomen  of  a  male,  age  39,  wilh  early  inguinal  hernia.     To  show  the  lateral  bulgings 
often  present  in  hernial  subjects.     {Macready.) 


greater  or  lesser  degree  throughout  life  in  nearly  all  people,  and 
the  second  being  particularly  active  before  puberty. 

There  is  a  form  of  abdomen  which  some  authors  think  is 
strongly  predisposed  to  hernia,  which  was  first  described  by 
Malgaigne  as  "  Triple  Bulging,"  and  by  Velpeau  it  was  classed 
as  ventral  hernia.  It  is  fairly  well  illustrated  in  fig.  14.  The 
median  bulge  is  due  apparently  to  the  strong  contraction  of 


CAUSE  OF  INGUINAL  HERNIA.  49 

the  recti  muscles,  (liniinisliing  tlie  antero-posterior  diameter 
of  the  abdomen,  and  causing  the  inguinal  region  to  bulge  on 
either  side.  Some  of  these  cases  seem  due  to  excessive  strength 
in  the  recti,  rather  than  to  any  special  weakness  in  the  side 
muscles  of  the  abdomen.  1  have  watched  some  of  them  for 
years,  where  the  conditicjn  was  marked,  without  seeing  hernia 
develop. 

7.  Fat. — That  fat,  either  in  excess,  or  suddenly  acquired, 
is  i)ro(luctive  of  inguinal  hernia,  is  abundantly  proven.  It  acts 
in  several  ways:  (a)  B}-  increasing'  intra-aljdominal  ])ressure; 
{b)  by  slipping  into  the  canal,  the  point  of  least  resistance 
under  violent  muscular  exertion;  (c)  by  the  formation  of  sub- 
peritoneal lipoma,  whicli  may  descend  through  the  canal,  drag- 
ging with  it  a  process  of  peritoneum  which  then  becomes 
hernial  sac;  (d)  fat  acquired  by  excessive  beer  drinking,  has 
been  found  particularly  productive  of  hernia,  by  a  two-fold 
action.  First,  in  the  accumulation  of  fat ;  second,  in  causing 
fatty  degeneration  of  muscular  tissue.  This  condition  makes 
these  patients  poor  subjects  for  the  curative  operation,  increas- 
ing the  danger  and  diminishing  the  chances  of  permanent  cure. 
rVbnormally  weak  and  premature  children  are  especially  prone 
to  the  occurrence  of  hernia  in  the  early  months  of  life,  and 
debility  from  old  age,  or  other  causes,  frequently  leads  to  it. 
Those  suffering  from  pulmonary  tuberculosis  are  particularly 
susceptible,  as  thev  not  only  have  the  relaxation  of  tissue,  but 
also  have  the  cough  as  a  direct  cause. 

The  theories  suggested  in  the  early  studies  (^f  the  causa- 
tion of  hernia  seem  rather  unimpt^rtant  in  \-iew  of  recent 
experience.  Most  writers  ha\'e  sided  with  either  those  who 
have  assigned  the  predisposing  cause  of  hernia  to  purely  me- 
chanical reasons,  or  with  those  who  claimed  that  it  was  due  to 
pathological  changes.  Those  holding  to  the  mechanical  causa- 
tion, adhere  to  the  belief  that  relaxation  of  the  abdominal 
muscles  is  the  primapy^  cause,  wdiile  the  '*  pathologists  "  believe 
that  in  the  abnormal  lengthening  of  the  mesentery  we  may  find 
the  first  change  which  results  in  abdominal  liernia. 
4 


50  ABDOMINAL  HERNIA. 

Anatomists  have  given  the  normal  length  of  the  mesen- 
teiy,  from  its  vertebral  attachment  to  its  intestinal  border,  as 
from  six  to  nine  inches.  It  is  quite  evident,  therefore,  that  in 
many  of  the  hernise  of  large  size,  the  elongation  of  this  attach- 
ment must  be  considerable.  Experience  during  the  past  de- 
cade, with  an  operation  that  corrects  a  mechanical  defect  in  the 
abdominal  wall,  and  cures  permanently  a  large  percentage  of 
these  hernise.  of  enormous  size  with  lengthened  mesenteries, 
seems  to  prove  conclusively  that  the  primary  cause  it  not  in  the 
length  of  the  mesentery. 

The  problem  of  curing  the  defect  having  been  solved,  it  is 
not  in  accord  with  the  purposes  of  this  work  to  further  consider 
theoretical  causes. 

IMMEDIATE    OR    DIRECT    CAUSES. 

The  immediate  causes  of  inguinal  hernia  are  too  numerous 
to  allow  of  naming  each  one.  Any  violent  muscular  compres- 
sion of  the  abdominal  contents  may  act  as  a  direct  cause  of 
hernia. 

The  following  is  a  partial  list  and  will,  perhaps,  be  sug- 
gestive of  many  others  not  enumerated :  (i)  Constipation:  (2) 
Vomiting;  (3)  Cough;  (4)  Lifting;  (5)  Shouting;  (6) 
Posture;  (7)  Obstructions  to  urination;  (8)  Crj-ing  in  chil- 
dren; (9)  Acites. 

1.  Constipation. — After  many  years  of  obser\ation  I  do 
not  hesitate  to  place  constipation  at  the  head  of  the  list.  The 
history  of  an  attack  of  obstinate  constipation  immediately  pre- 
ceding the  discovery  of  a  swelling  in  the  groin  is  surprisingly 
common,  and  at  once  suggests  an  important  part  of  the  subse- 
quent treatment  of  the  case.  In  chronic  constipation  the  cause 
is  more  effective  in  that  there  is  longer  continued  repetition  of 
the  straining  at  stool  and  greater  distention  of  the  bowel. 

2.  Vomiting. — Straining  during  this  act  is  frec|uentlv  an 
immediate  cause  in  an  indi\Mdual  otherwise  predisposed  to 
hernia. 


CAUSE  OF  INGUINAL  HERNIA.  51 

3.  Cough. — Violent  and  persistent  couching,  as  in  whoop- 
ing cough,  chronic  bronchitis,  and  phthisis,  are  active  catises, 
as  may  also  be  an  elongated  uvula  with  resultant  violent  cough. 

4.  Lifting. — This  is  a  common  direct  cause  (jf  inguinal 
hernia,  but  no  more  so  to  the  laborer  than  to  the  merchant  or 
editor.  The  muscles  of  the  working  man  are  trained  to  their 
work  and  when  he  makes  even  a  heavy  lift,  they  protect  him. 
It  is  when  he  is  caught  suddenly,  unprepared,  that  harm  comes. 
The  merchant  or  clerk  is  unaccustomed  to  heavy  work-,  but 
upon  occasion  takes  hold  "with  the  boys  "  and  his  muscles  not 
trained  to  withstand  the  strain,  the  effort  frequently  results  in 
hernia. 

A  former  patient  was  in  charge  of  the  gymnasium  in  (jne 
of  the  larger  colleges  and  was  accustomed  to  lead  in  all  of  the 
exercises  which  he  taught,  and  felt  that  he  could  exceed,  in 
strength  tests,  any  of  the  younger  men.  He  gave  this  occupa- 
tion up  to  become  the  editor  of  a  daily  paper,  and  in  this  posi- 
tion was  closely  confined  to  his  desk.  It  was  a  mystery  to  him 
why,  after  he  had  abandoned  very  active  and  extreme  exercise, 
that  he  should  develop  hernia.  The  mystery  was  explained 
wdien  it  was  discovered  that  he  had  in  his  hrjme  a  pair  of  extra 
heavy  dumb-bells,  his  pets  of  former  days,  with  which  he  exer- 
cised at  rare  intervals. 

5.  Shouting. — The  vigorous  calling  out  of  wares  in  the 
open  streets,  as  done  by  hucksters,  pedlers,  and  street  fakirs,  is 
quite  liable  to  bring  on  hernia,  and  it  is  very  hard  to  treat  them 
successfully  by  mechanical  means  or  cure  them  by  operation  as 
long  as  they  continue  their  occupation. 

6.  Posture. — There  are  certain  positions  of  the  body 
which  favor  the  occurrence  of  hernia,  i.e.,  any  muscular  effort, 
while  the  abdominal  muscles  are  relaxed,  as  in  stooping  for- 
ward, or  while  the  arms  are  extended  o\er  the  head.  Golf  has 
furnished  a  fairly  large  number  of  herni?e  in  men  past  middle 
life.  The  schools  that  teach  so-called  "  Physical  Culture  bv 
Correspondence  "  aid  many  middle-aged  men  in  producing 
hernia.       The   reason   that   T   name  particularlv   this  class   of 


52 


ABDOMINAL  HERNIA. 


schools,  is  to  point  out  the  fact  that  the  fauh  Hes  more  in  the 
over-ambition  of  the  pupil,  than  in  the  lack  of  knowledge  on 
the  part  of  the  teacher.  I  feel  warranted  in  illustrating  here 
an  exercise  that  has  brought  under  my  notice  from  6  to  lo 
cases  of  hernia  a  year  (fig.  15).  This  consists  in  throwing 
the  body  back  as  far  as  possible,  with  the  hands  above  the  head, 

Fig.  15. 


A  form  of  "  Physical  Culture"  that  produces  many  lierniae  in  men  past  middle  age. 


and  then  stooping  forward  until  the  finger  tips  rest  upon  the 
floor.  This  one  exercise  had  apparently  been  the  cause  in 
these  cases;  at  least  this  is  the  only  one  form  that  all  had 
taken.  I  am  not  a  disbeliever  in  physical  exercise,  even  for 
those  who  ha^•e  hernia  as  I  shall  demonstrate  later,  but  I 
do  think  that  those  past  the  muscle  building  age  should  not 
resort  to  it  excei)t  under  strict  personal  supervision  of  an 
instructor. 


CAUSE  OF  INGUINAL  HERNIA.  53 

7.  Urinary  Obstructions. — These  urinary  disturbances, 
either  as  stricture,  calcuh,  or  prostatic  enlargement,  may  easily 
lead  to  the  development  of  hernia.  Men  who  have  prostatic 
trouble  are  especially  liable  tcj  it,  both  on  account  of  the  strain- 
ing in  attempted  urination,  and  to  the  fact  that  this  trouble 
usually  occurs  at  a  time  of  life  when  the  tissues  are  not  in 
condition  to  withstand  this  frequently  repeated  strain. 

8.  Crying. — In  infancy  and  early  childhood  there  is  no 
doubt  that  crying  has  an  important  place.  The  infant  is 
strongly  predisposed  to  hernia  by  its  short  canal  and  develop- 
mental imperfections ;  add  to  these  constipation  and  crying, 
and  we  have  two  very  active  direct  causes. 

One  other  cause  that  I  do  not  see  as  frequently  as  in  my 
earlier  years  of  experience,  is  the  belly-band  that  "grand- 
mother "  said  "  must  be  very  tight  or  the  baby  could  not  be 
expected  to  thrive."  By  having  the  belly-band  tight  the  intes- 
tines are  driven  into  the  lower  abdomen  and  extreme  pressure 
made  upon  the  delicate  tissues,  especially  when  the  child  cries. 

Crying  may  not  only  act  as  an  immediate  cause,  but  it  is 
very  sure  tO'  aid  in  increasing  its  size  rapidly,  when  hernia  is 
once  formed.  When  the  infant  cries,  and  the  bowel  is  forced 
into  the  canal,  causing  pain,  this  in  turn  causes  the  child  to  cry 
more. 

9.  Acites. — An  effusion  of  fluid  into  the  abdominal  cavity 
is  spmetimes  the  origin  of  inguinal  hernia,  but  for  obvious  rea- 
sons such  cases  are  not  common. 

In  addition  to  the  above  enumerated  causes,  phimosis 
has  been  mentioned  by  eminent  writers  as  a  direct  cause 
of  hernia,  otherwise  it  would  not  be  referred  to  here.  If 
the  foreskin  is  so  long  or  the  opening  in  it  so  small  as  to  cause 
the  child  to  strain  when  he  urinates,  then  w^e  have  a  reasonable 
cause  of  hernia,  otherwise  not.  Very  rarely  has  such  a  case 
been  seen ;  furthermore,  in  the  Jewish  orphan  asylums  where 
all  of  the  male  children  have  been  circumcised  in  early  infancy 
the  usual  proportion  of  hernia  exists. 


CHAPTER  IV. 

TYPES  AND   CONDITIONS   OF   INGUINAL  HERNIA. 

In  early  writings  upon  the  subject,  and  even  in  many  of 
more  recent  date,  the  divisions  and  subdivisions  of  inguinal 
hernia  have  been  so  numerous  and  its  nomenclature  so  prolific, 
that  much  unnecessary  confusion  has  been  added  to  an  already 
complex  subject.  Accepting  risk  of  criticism,  I  have  en- 
deavored to  simplify  this  division  to  the  extreme  limit,  and  to 
use  only  those  temis,  so  far  as  possible,  which  carry  with  them 
their  own  meaning. 

The  necessary  divisions  for  the  proper  consideration  of 
inguinal  hernia  are :  Oblique,  direct,  sigmoid  or  ccccal,  and 
interstitial  hernia.  Fig.  i6  shows  tAvo  oblique  and  one  direct 
hernia  in  the  same  patient. 

The  oblique  type  may  either  be  of  the  congenital,  or  of  the 
acquired  form.  In  degree  of  development  the  congenital  is 
nearly  always  a  scrotal  (or  labial)  hernia,  as  when  it  passes  the 
inguinal  canal  it  drops  into  a  preformed  sac.  Acquired  hernia, 
on  the  contrary,  may  be,  according  to  its  degree  of  development, 
either  incomplete,  complete,  ov  scrotal  (or  labial)  in  character. 
Direct  inguinal  hernia  seldom  becomes  scrotal  in  character  even 
though  it  attains  large  proportions. 

Sigmoid  or  Csecal  hernia  belongs  to  the  direct  hernia  type, 
but  on  account  of  its  peculiar  anatomical  characteristics  must 
be  considered  under  a  special  heading.  This  statement  holds 
equally  true  of  interstitial  hernia,  except  that  it  may  belong 
either  to  the  acquired  or  congenital  type,  but  very  rarely  to 
direct  hernia. 

Oblique  inguinal  hernia  is  so  called  because  the  pro- 
trusion enters  the  inguinal  canal  at  the  internal  abdominal 
ring  and  passes  obliquely  through  the  abdominal  wall.  If  it 
protrudes  into  the  canal  only,  it  is  then  called  incomplete  in- 

54 


TYPES  OF  INGUINAL  HERNIA. 


55 


guinal  hernia  (see  fig.  17).  if,  however,  it  passes  out  (jf  the 
inguinal  canal  through  the  external  abdominal  ring,  then  it 
becomes  coiitplclr  ()1)lique  inguinal  hernia  (see  fig.  18,  right 
side).  If  these  small  herni^e  are  neglected  or  unskillfully  cared 
for,  they  become  by  progressive  development  scrotal  hernia  in 
the  male    (figs.    18  and   19),  or  labial  hernia  in  the  female 

Fig.  16. 


A  male,  age  79,  having  an  oblique  inguinal  hernia  in  an  early  stage,  and  a  direct  hernia  on 
the  left  side,  and  on  the  right  side  an  oblique  hernia  more  advanced  than  that  on  the  left. 
(Macready.) 


(^fig.  20).  The  terms  "  scrotal  "  and  ''  labial  "  indicate  a  stage 
of  growth  and  should  not  be  used  to  designate  types  of  hernia. 
Some  truss  manufacturers  make  what  they  call  a  "  scrotal- 
hernia  truss,"  which  is  based  upon  the  idea  that  it  is  for  a 
special  type  of  hernia,  and  it  is  only  mentioned  here  because 
the  author  knows  that  some  misapprehension  exists  in  the 
minds  of  many  practitioners. 


56 


ABDOMINAL  HERNIA. 


Oblique  inguinal  hernia  may  protrude  into  a  preformed 
sac,  present  at  birth  (from  lack  of  obliteration  of  the  tunica 
vaginalis),  in  which  case  it  forms  a  congenital  hernia.  This 
protrusion  may  occur  after  the  person  has  reached  adult  life, 
even  though  the  defect  has  existed  during  all  of  the  preceding 
years,  but  by  far  the  greater  number  of  congenital  hernide  do 
occur  in  infancy  or  early  childhood.     When  we  speak  of  con- 


FiG.  17. 


Incomplete  inguinal  hernia  on  iett.    Direct  inguinal  hernia  on  right,  poorly  shown.  (Eccles.) 

genital  hernia,  therefore,  it  does  not  indicate  at  what  age  such 
hernia  may  have  developed,  but  does  clearly  mean  that  the 
hernia  has  come  down  into  a  sac  already  formed. 

Acquired  inguinal  hernia  refers  to  a  condition  wherein  the 
protruding  mass  carries  with  it,  as  a  sac  covering,  the  peritoneal 
lining  of  the  abdomen.  This  peritoneal  pouch  is  known  as  the 
hernial  sac  and,  in  the  course  of  time,  loses  some  of  its  char- 
acteristics as  peritoneum  by  becoming  thickened  and  otherwise 
changed   in   structure.      It  continues,   however,    as   a   moist. 


TYPES  OF  INGUINAL  HERNIA. 


57 


serous   mebrane,    and   as   such    favors   the   protrusion    of  the 
abdominal  contents. 

Direct  inguinal  hernia  does  not  enter  the  upper  part  of  the 
inguinal  canal  at  the  internal  ring,  but  protrudes  directly 
through  the  external  abdominal   ring  and  presents  a  tumor 

Fig.  i8. 


Showing  on  the  right  side  a  complete  oblique  inguinal  hernia.  On  the  left  an 
enormous  oblique  inguinal  (scrotal)  hernia.  Circumference,  32  inches;  within  two  inches 
of  knee-joint. 


circular  in  fonn  that,  even  though  it  is  large,  has  little  tendency 
to  descend  into  the  scrotum  (fig.  21).  A  tumor  as  large  as  a 
cocoanut  has  been  seen  standing  out  from  the  body  over  the 
pubic  bone.  Tumors  of  this  type  should  be  approached  bv  the 
operator  with  care,  as  they  are  liable  to  contain  the  fundus  of 
the  bladder,  or  they  may  prove  to  be  sigmoid  hernia  as  shown 


5H 


ABDOMINAL  HERNIA. 


in  fig.  22.  The  deep  epigastric  artery  passes  across  the  inguinal 
canal  just  below  the  internal  abdominal  ring,  and  oblique 
hernia  passes  over  it  in  going  down  the  canal.  Direct  inguinal 
hernia,  on  the  contrary,  passes  through  the  abdominal  wall 
inside  of  the  artery,  towards  the  median  line.     This  is  usually 

Fig.  19. 


Showing  the  enormous   size  which  scrotal   herniae  may  attain   by   neglect.     Right  oblique 
inguinal  hernia  (scrotal)  in  a  man  over  70  years  of  age. 


SO,  but  in  some  persons  with  abnormally  short  canals  the 
artery  runs  lower  down,  and  while  actually  the  protrusion  is 
oblique,  it  has  e\'ery  appearance  of  a  direct  hernia.  It  must 
be  remembered  therefore  in  operating,  that  the  deep  epigastric 
artery  may  be  found  at  either  side  of  the  neck  of  the  hernial 
sac. 


TYPES  OF  INGUliNAL  HERNIA. 


59 


Hernire  of  the  direct  type  are  not  met  with  as  frequently  in 
women  as  in  men,  and  the  reasons  for  this  are  shown  in  the 
recent  studies  of  Marie  Donati  {Archiviu  per  Ic  Slicnzc 
Mcdischc,  No.  3,  1905;  Al)stract  Medical  Record,  July  8. 
1905).  He  believes  that  "the  smaller  number  of  the  direct 
inguinal  type  that  we  find  in  women,  is  due  to  the  different 
formation  of  the  inguinal  canal  in  the  two  sexes,  and  to  estab- 

FlG.   20. 


Showing  oblique  inguinal  (labial)  hernia  in  a  woman  of  45  years. 

lish  this  conclusion  he  has  dissected  52  cada\'ers  of  b(~»th  sexes. 
31  women.  21  men,  and  has  found  marked  differences  in 
them.  The  aponeurosis  of  the  insertion  of  the  great  oblique 
muscles  has  linear  interstices,  which  are  much  larger  in  the 
male  than  in  the  female.  The  pillars  of  the  internal  oblique 
are  stronger  in  front  of  the  canal  in  women.  The  arciform 
fibres  (inter-crural)  are  in  women  often  mingled  with  cross 
fibres  which  strengthen  the  ring,  which  are  absent  in  men.   The 


60 


ABDOMINAL  HERNIA. 


orifice  of  the  external  inguinal  ring  is  generally  smaller  in 
females  than  in  males.  It  is  generally  situated  higher  and  a 
little  more  external  in  men  than  in  women,  contrary  to  what 
has  been  supposed  to  be  the  case.  The  aponeurosis  of  the  large 
oblique,  which  forms  the  anterior  wall  of  the  canal,  is  much 
stronger  in  the  female  sex  than  in  the  male.  The  lower 
margin  of  the  ring  in  women  is  more  horizontal,  that  in  the 

Fig.  21. 


Double  direct  hernia.     (Macready.) 


male  more  oblique.  Hence  this  point,  which  is  often  weak  in 
the  male,  is  in  the  female  most  resistant."' 

Sigmoid  hernia,  the  beginning  of  which  is  usually  that 
of  a  direct  inguinal  hernial  protrusion,  has  certain  peculiari- 
ties in  its  development  which  make  it  essential  that  it  should 
have  a  distinctive  classification,  and  none  of  the  terms  applied 
to  it  seems  so  descriptive  as  the  one  here  used. 

It  will  be  remembered  that  the  peritoneum  not  only  lines 
the  cavity  of  the  abdomen,  but  envelops  most  of  the  hollow 


TYPES  OF  INGUINAL  HERNIA. 


01 


organs,  fcjrniing-  Ixick  oi  thcni  the  mesentery  which  gives  them 
partial  support.  In  the  case  of  the  sigmoid  flexure,  the  caicum, 
and  the  l)ladder,  this  covering  is  only  partial.  The  sigmoid 
flexure  is  covered  in  front  and  on  the  sides,  hut  a  ])ortion  of  a 
back  part  of  the  bowel  is  in  direct  contact  with  the  ])osterior 
wall  of  the  pelvis   (iliac  fossa).      When  hernia  occurs  to  this 

Fig.  22, 


Sigmoid  hernia.    Peritoneal  covering  in  front  of  intestine,  none  at  its  back.    Loops  of  small 
intestine  protruding  in  front  of  sigmoid  flexure. 


part  of  the  large  bowel  it  pushes  through  the  abdominal  wall, 
carrying  the  portion  of  peritoneum  that  is  in  front  as  a  peri- 
toneal pocket  into  which  other  parts  of  intestine  may  protrude. 
The  posterior  intestinal  wall,  as  it  ])rotrudes,  usually  precedes 
the  part  covered  by  peritoneum,  forming  the  most  prominent 
part  of  the  tumor,  and  is  entirely  devoid  of  peritoneal  cover- 
ing. If  the  operator  does  not  anticipate  this  condition,  and 
opens  low^  down  on  the  tumor  he  will  find  that  he  has  made  an 


62  ABDOMINAL  HERNIA. 

incision  directly  into  the  large  bowel.  If,  however,  he  be  so 
fortunate  as  to  open  high  up  on  its  anterior  surface,  he  will 
then  haAe  opened  into  the  sac  which  is  in  communication  with 
the  peritoneal  cavit}-.  recognize  the  true  condition,  and  thus 
prevent  an  embarrassing  situation. 

Fig.  23. 


Direct  inguinal  hernia  on  the  right;  sigmoid  hernia  on  the  left.     The  illustration  is  typical  of 
the  peculiar  shape  of  sigmoid  protrusions. 


In  treating  of  diagnosis,  suggestions  will  be  made  that  may 
aid  in  recognizing  this  condition  before  operation,  but  this  can 
not  always  be  done.  It  is  fortunate  that  I  am  able  to  present 
the  photograph  of  such  a  typical  case  as  that  show^i  in  fig  23. 
On  the  right  side  an  ordinary  direct  inguinal  hernia  appears ; 
on  the  left  side  can  be  seen  what  proved  at  operation  to  be  a 
hernia  of  the  sigmoid  flexure.  Its  size  has  pushed  it  down  to 
the  top  of  the  scrotum,  but  it  is  not  a  true  scrotal  hernia. 


TYPES  OF  INGUINAL  HERNIA. 


63 


Cascal  (ingminalj  hernia  does  not  assume  the  importance 
of  tlie  sigmoid  type,  Ijoth  on  account  of  its  i^reater  rarity  and 
from  the  fact  tliat  tlie  conditions  ])resented  by  it  are  not  as 
h'able  to  lead  to  disastrous  results.  The  free  Ct'ecum  and  the 
ai)pendix  \ermiformis  are  not  uncommon  occupants  of  a  true 
hernial  sac,  but  these  are  Ufjt  termed  CcCcal  hernia.      It  is  cmly 

Fig.  24. 


Left  interstitial  hernia  caused    by  delayed  descent  of   testicle.      Right   testicle  is  inside  of 
external  abdominal  ring. 


when  the  colon  slides  down  so  that  the  portion  not  covered  by 
peritoneum  forms  a  part  of  the  protrusion  that  it  is  gi\-en  this 
title. 

Interstitial  inguinal  hernia.  Included  under  this  title  will 
be  considered  all  of  those  hernicT  that  ha\"e  been  variously 
termed  "  properitoneal,"  "interparietal,"  "bubonocele  rara," 
"  superficial   inguinal,''   and   "  interstitial."     Any   hernia   tliat 


64 


ABDOMINAL  HERNIA. 


protrudes  between  the  layers  of  muscle,  or  tissue,  which  con- 
stitute the  abdominal  wall  at  this  point,  will  be  termed  inter- 
stitial hernia.  Such  hernise  usually  begin  as  oblique  inguinal 
hernia  and,  in  their  passage  clown  the  canal,  meet  with  some 
obstruction  which  turns  them  to  some  point  of  less  resistance. 
Ordinarily  these  diverticula  of  the  hernial  sac  are  small,  but 

Fig.  25. 


A  right  interstitial  hernia,  associated  with  the  right  testis  in  the  canal.    {Eccles.) 


sometimes  they  reach  proportions  quite  in  excess  of  the  size  of 
the  true  sac. 

Interstitial  hernia,  in  the  male,  is  very  frequently  asso- 
ciated with  the  imperfect  descent  of  the  testicle  as  shown  in 
fig.  24,  but  a  similar  condition  is  not  infrequently  met  with  in 
the  female.  I  have  seen  two  such  herniie  in  the  female  that 
were  associated  with  an  ovary  contained  in  the  same  sac,  show- 
ing a  probable  formation  identical  wit1i  the  imperfectly 
descendefl  testicle  in  the  male.     The  ovarv  had  first  entered  the 


TYPES  OF  INGUINAL  HERNIA. 


65 


canal  followed  by  the  hernia,  which,  being-  obstructed  in  its 
downward  course,  crowded  itself  between  the  abdominal  layers. 
These  i)rotrusions  may  be  between  any  of  the  layers  of  the 
abdominal  wall,  but  will  be  found  most  frequently  in  the  order 
named:  (i)  Beneath  the  aponeurosis  of  the  external  oblique, 
and  between  this  structure  and  the  internal  oblique.     Such  a 

Fig.  26. 


The  right  testis  in  a  cruro-scrotal  pouch,  accompanied  by  a  hernia.     {Eccles.) 


formation  is  shown  in  fig.  25,  as  well  as  in  the  one  just  referred 
to.  (2)  Into  the  subperitoneal  fat  between  the  peritoneum 
and  the  transversalis  fascia.  (3)  Between  the  skin  and  ex- 
ternal oblicjue  muscle,  or  into  the  tissues  of  the  thigh  as  shown 
in  fig.  26. 

In  formation  the  first  type  most  frequently  develops 
towards  the  iliac  crest.  The  form  that  passes  under  the  fascia 
transversalis    more    frequently    fomis    a   pocket   towards    the 

5 


66  ABDOMINAL  HERNIA. 

median  line,  while  that  forming  immediately  beneath  the  skin 
may  go  in  almost  any  direction.  A  hernia  of  the  latter  type  is 
shown  in  fig.  27,  which  has  dissected  up  the  subcutaneous 
tissues  of  the  thigh  and  simulates  femoral  hernia  (fig.  28). 
Not  only  may  these  hernise  develop,  from  obstructions  within 
the  canal,  but  some  that  I  have  operated  upon  have  been  the 

Fig.  27. 


Interstitial  hernia.  The  right  half  of  the  scrotum  is  absent  and  the  testis,  which  is  very 
small,  lies  within  the  canal  near  the  external  ring.  The  external  oblique  is  in  front  of  the 
hernia.    From  a  man,  age  50.     {Macready.) 

result  of  trusses  improperly  applied.  The  truss  pad  had  ob- 
structed the  passage  of  the  hernia  through  the  external 
abdominal  ring,  but  had  not  kept  it  out  of  the  canal.  The  sac 
had,  therefore,  enlarged  laterally  where  there  was  less  re- 
sistance. 

Interstitial  hernia  that  forms  between  the  peritoneum  and 
transversalis  fascia  is  believed  to  be  the  most  dangerous  type  of 


TYPES  OF  INGUINAL  HERNIA. 


67 


this  class,  owing  to  its  greater  liability  to  become  strangulated 
and  to  the  obscure  location  of  the  exact  place  of  strangulation. 
This  was  strongly  impressed  upon  me  several  years  ago  while 
operating  upon  a  woman  seventy-five  years  old,  for  a  strangu- 
lated inguinal  hernia.     On  opening  into  an  ordinarv^  inguinal 

Fig.  28. 


Literstitial  hernia,  falling  over  the  thigh  and  simulating  femoral  hernia;  in  a  man,  age  56. 

{Macready.) 


sac  it  was  found  to  contain  small  intestine,  in  fairly  normal 
condition,  which  was  reduced  without  much  difficulty.  A 
tumor  was  then  discovered  nearer  the  median  line,  which  was 
found  to  be  an  interstitial  sac  just  outside  of  the  peritoneum, 
and  it  was  in  the  neck  of  this  sac  that  strangulation  existed. 
The  form  of  the  sac  is  roughly  shown  in  the  following  illustra- 
tion (fig.  29). 


68 


ABDOMINAL  HERNIA. 


Conditions. — The  conditions  in  which  inguinal  hernia 
may  be  found,  at  the  first  examination,  are  as  follows :  Re- 
ducible, irreducible,  incarcerated,  inflamed,  or  strangulated. 

Reducible  inguinal  hernia  is  where,  irrespective  of  its  size, 
its  contents  are  wholly  reducible  to  the  cavity  of  the  abdomen. 
Such  hernias  are  uncomplicated  and  can  usually  be  retained 
within  the  abdomen  by  truss  pressure.  In  infants  this  method 
of  treatment  may  result  in  a  permanent  cure,  but  in  adult 
life  this  fortunate  result  is  rarely  obtained.     The  truss  ordi- 


FlG.   29. 


A,  Abdominal  cavity.     B,  Sac  in  inguinal  canal.    C,  Interstitial  sac.    D,  Neck  of  interstitial 
sac,  where  strangulation  existed. 

narily  guards  against  strangulated  hernia,  providing  its  design 
and  fitting  are  suited  to  the  requirements  of  the  case. 

Irreducible  hernia  may  occur  from  one  of  many  causes. 
(a)  A  very  large  mass  of  the  abdominal  viscera,  either  intes- 
tine or  omentum,  may  protrude  gradually  through  a  small  neck 
into  the  sac,  and,  when  attempts  at  reduction  are  made,  give  the 
case  the  appearance  of  an  irreducible  hernia.  Such  a  case,  by 
])crfect  rest  in  l)cd  and  repeated  gentle  taxis,  would  be  readily 
conveited  into  a  reducible  hernia  and  could  then  be  treated  as 
such,  (b)  Omentum  tliat  is  allowed  to  remain  in  a  hernial 
sac,  is  under  pressure  at  its  neck,  and  this  partial  obstruction  to 


TYPES  OF  INGUINAL  HERNIA.  69 

the  return  flow  of  blood  may  cause  an  enlargement  or  nyper- 
trophy  of  the  omental  mass.  The  omentum  becomes  hard  and 
nodular  and  without  undue  violence  it  cannot  be  forced  back 
through  the  small  neck  of  the  sac.  Even  when  this  can  be 
done,  it  is  attended  by  much  danger,  the  hypertrophied  omen- 
tum acting  as  a  foreign  body  within  the  abdominal  cavity. 

In  my  early  experience  with  hernia,  when  operations  were 
attended  by  more  risk  and  the  ultimate  result  far  from  satis- 
factory, while  I  had  no  actual  mortality,  I  was  more  than 
once  concerned  regarding  the  welfare  of  my  patient,  upon  whom 
I  had  succeeded  in  reducing  what  appeared  to  be  an  irreducible 
hernia.  In  the  present  day,  work  of  this  type  is  seldom  justifi- 
able, as  the  skillful  surgical  care  of  the  case  is  probably 
attended  by  much  less  risk  and  by  an  incomparably  greater 
degree  of  success,  (c)  The  reduction  of  hernia  may  be  pre- 
vented by  adhesions  of  the  protruding  parts  to  the  sides  of  the 
hernial  sac.  These  adhesions  most  commonly  occur  between 
omentum  and  the  sac  wall.  Adhesions  between  protruding  in- 
testine and  the  sac  wall  are  more  rare  than  those  involving  the 
omentum,  because  of  the  peristaltic  action  of  the  bowel.  Intes- 
tine, even  when,  packed  into  a  sac  in  large  cjuantities,  must  con- 
tinue this  action  in  order  to  carry  forward  its  contents,  and 
this  constant  motion  undoubtedly  frequently  prevents  adhe- 
sions. Bowel  in  this  abnormal  position,  however,  becomes 
constantly  less  active  and  is  still  further  crippled  by  adhesion  to 
the  sac  wall.  If  only  a  small  area  is  adherent  the  bowel  still' 
performs  its  function,  but  as  a  greater  amount  becomes  disabled 
obstinate  constipation  is  followed  by  intestinal  obstruction,  and 
then,  even  the  art  and  science  of  surgery  is  powerless  to  afi^ord 
more  than  temporary  relief.  In  such  cases,  when  operation 
for  strangulated  hernia  is  resorted  to,  the  patient  for  a  few  days 
may  appear  to  have  been  rescued  from  death,  but  symptoms  of 
intestinal  obstruction  gradually  reappear  and  death  follows. 
The  operation  releases  the  bowel  from  imprisonment,  and  at 
that  time  it  may  appear  to  be  in  fairly  good  condition,  but  its 
paralysis  has  been  complete  and  there  is  no  hope  of  recovery. 


70  ABDOMINAL  HERNIA. 

Incarcerated  hernia  is  a  form  which,  though  ordinarily 
reducible,  has  for  some  cause  become  temporarily  irreducible. 
There  is  no  strangulation  of  tissue,  however,  and  no  symptoms 
of  intestinal  obstruction,  hence  the  term  as  here  used  is  not 
intended  to  convey  the  idea  of  strangulation.  (These  two  con- 
ditions are  frequently  confused  in  the  medical  mind.)  If  the 
protruding  contents  of  the  sac  are  intestine,  the  bowel  may 
have  become  twisted  in  such  a  manner  that  for  the  time  being 
its  return  is  prevented,  but  the  pressure  upon  the  bowel  is  not 
sufficient  to  produce  stasis,  either  of  its  blood  supply  or  its  con- 
tents. When  the  protruding  contents  are  mostly,  or  wholly, 
omentum,  the  cause  of  irreducibility  may  be  identical  with  that 
just  named.  An  incarcerated  hernia  is  not  a  condition  of  im- 
mediate danger,  but  may  become  so  in  two  different  ways.  If 
intestine  is  involved,  acute  intestinal  obstruction  may  result  at 
any  moment,  while  if  omentum  forms  the  bulk  of  the  tumor, 
it  may  become  inflamed,  adding  to  the  danger. 

Inflamed  hernia  is  a  term  that  should  be  limited  to  those 
cases  of  omental  protrusion  where  this  structure  has  become 
inflamed,  which  condition  is  most  frecjuently  brought  on  by 
over-violent  attempts,  either  by  the  patient  or  his  medical  at- 
tendant, to  reduce  a  mass  of  protruding  omentum.  The  bowel, 
if  also  protruding,  usually  comes  down  into  the  sac  back  of  the 
omentum  and  returns  to  the  abdominal  cavity  upon  the  patient 
assuming  a  recumbent  position.  If  the  bowel  is  prevented  from 
returning,  the  case  is  quite  sure  to  result  in  strangulated  hernia. 

Strangulated  hernia  is  a  type  in  which  the  intestine  is 
usually  the  part  involved,  although  we  may  meet  with  cases 
where  it  is  the  omentum,  or,  as  most  commonly  occurs,  both 
intestine  and  omentum  are  present.  As  this  accident  v/ill  be 
fully  considered  under  a  special  heading",  it  will  not  be  necessary 
to  treat  of  it  here  further  than  to  say  that  it  usually  presents  a 
picture  of  acute  intestinal  obstruction  with  its  accompanying 
intense  physical  suffering. 


CHAPTER  V. 

THE  HERNIAL  SAC. 

Formation. — In  order  to  comprehend  more  clearly  the  con- 
ditions in  which  we  may  find  hernia,  some  consideration  must 
be  given  to  the  formation  and  development  of  hernial  sac.  It 
usually  begins  by  the  bulging  forward  of  the  peritoneum  into 
one  of  the  hypogastric  fossae.  If  the  hernia  is  to  be  of  the 
direct  type,  it  is  into  the  fossa  between  the  epigastric  artery 
and  the  median  line;  if  oblique,  into  the  external  hypogastric 
fossa  outside  of  the  epigastric  artery.  This  bulging  may  occur 
under  some  unusual  strain,  and  the  elasticity  of  the  peritoneum 
is  such  that  it  will,  perhaps  many  times,  recover  its  normal 
smooth  surface,  but  when  this  undue  stretching  is  repeated  too 
frequently,  or  too  violently,  a  pocket  is  formed  in  the  canal 
lined  with  peritoneum.  From  that  moment  the  peritoneal  lin- 
ing of  this  pocket  becomes  the  hernial  sac,  and  it  is  with  its 
increase  in  size  and  change  in  character  that  we  have  to  deal. 

It  is  highly  probable  that  a  sac  in  the  early  period  of  its 
formation  may  be  reducible,  as  well  as  its  contents,  but  as  a 
matter  of  fact  we  do  not  find  it  so  upon  the  operating  table, 
even  though  the  case  be  one  of  very  recent  origin.  Doubtless 
very  shortly  after  its  protrusion,  it  forms  firm  adhesion  to  the 
surrounding  tissues.  Its  subsequent  development,  dependent 
somewhat  upon  the  treatment  of  the  hernia,  is  one  of  growth 
both  in  size  and  thickness  of  the  tissue  of  which  it  is  composed. 
An  old  and  large  hernial  sac  has  lost  entirely  the  characteristics 
of  peritoneum.  The  thickening  of  its  structure  may  be  uni- 
form or  it  may  become  thickened  in  some  parts  while  it  remains 
thin  in  others,  but  it  is  no  longer  peritoneum,  nor  is  it  neces- 
sary to  treat  it  as  such.  Not  only  has  it  ceased  to  belong  to 
the  abdominal  cavity,  but  it  has  become  a  foreign  body  in  the 
canal,  and  a  cure  can  seldom  be  effected  until  it  is  completely 
eradicated. 

71 


72 


ABDOMINAL  HERNIA. 


There  are  certain  changes  in  structure  that  I  have  met 
with  frequently  in  operating,  that  have  been  httle  spoken  of  in 
works  on  hernia,  and  still  they  seem  to  me  important  because 
they  frequently  are  the  immediate  cause  of  strangulated  hernia, 
I  refer  to  fibrous,  tough,  inelastic  rings,  that  form  not  only  in 
many  old  sacs,  but  in  some  of  rather  recent  origin.  These 
rings  are  fairly  well  shown  in  fig.  30  taken  from  a  man  of 
thirty-five  years,  who  had  a  right  scrotal  hernia  for  ten  years. 

Fig.  30. 


Three  fibrous  rings  in  acquired  sac. 


When  I  first  began  to  meet  with  these  rings  I  supposed  that 
they  were  confined  to  congenital  sacs  and  represented  the  origi- 
nal points  of  closure,  or  obliteration,  of  the  tunica  vaginalis, 
but  further  observation  has  convinced  me  that  they  are  more 
frequent  in  sacs  of  the  acquired  form.  These  rings  are  so 
tough  that  if  a  loop  of  bowel  is  forcibly  driven  into  one  of 
them,  strangulation  is  quite  sure  to  result.  They  usually  sur- 
round the  entire  sac,  but  sometimes  only  a  portion  of  it,  the 
balance  of  the  sac  being  thin.  From  one  to  four  may  be  found 
in  the  same  sac,  located  at  any  point  from  the  vicinity  of  the 


THE  HERNIAL  SAC. 


7S 


testicle  to  the  internal  ring.  In  some  instances  they  have  nar- 
rowed the  sac  to  a  complete  closure  as  shown  at  the  lower  ring 
in  fig.  31.  In  this  case  intestine  and  bowel  were  found  strangu- 
lated in  the  upper  ring  while  the  pocket  below  the  lower  ring 
was  filled  with  fluid.  The  sac  was  unquestionably  of  the 
acquired  type  and  was  removed  entire  from  the  scrotum.  There 
was  no  communication  between  the  upper  and  lower  cavities. 

Fig.  31. 


Showing  two  fibrous  rings  in  sac.    Strangulation  of  intestine  and  omentum 
was  present  in  upper  one.    Lower  cavity  contained  fluid  only. 

Fig.  T,2  shows  a  similar  ring,  in  a  congenital  sac,  in  which  was 
incarcerated  (not  strangulated)  an  omental  protrusion.  This 
was  in  a  boy,  ten  years  of  age,  who  had  been  under  treatment 
for  some  time  and  who  was  wearing  a  truss.  Considerable 
thickening  was  felt  in  the  scrotum,  but  the  neck  of  omentum, 
connecting  with  the  abdomen,  was  small,  and  the  true  condi- 
tion was  not  recognized  until  the  operation.  In  this  work 
will  be  found  an  illustration  of  an  appendix,  the  end  of  which 
was  incarcerated  in  a  rino-  near  the  bottom  of  the  scrotum. 


74 


ABDOMINAL  HERNIA. 


Congenital  Sac. — It  has  been  already  stated  that  the  con- 
genital sac  is  present  at  birth  because  nature,  for  some  unknown 
reason,  has  failed  to  carry  to  completion  one  of  the  processes 
of  development.  This  applies  as  well  to  the  inguinal  canal  of 
the  female,  but  the  condition  with  her  is  unquestionably  more 
rare.  It  is  not  intended  to  repeat  here  what  has  been  said  in 
connection  with  the  descent  of  the  testicle  and  the  formation  of 
the  tunica  vaginalis,  but  to  call  attention  to  a  form  of  sac  where 

Fig.  32. 


Boy,  10  years  of  age,  with  omentum  incarcerated  by  ring  in  congenital  sac. 


the  hernia  is  in  the  funicular  portion  of  the  unobliterated  tunica 
vaginalis  (fig.  33).  In  these  cases  is  found  what  appears  to 
be  a  true  hernial  sac,  and  beneath  this  may  be  found  an  empty 
serous-lined  cavity,  or  a  cyst  filled  with  fluid  as  shown  in  fig.  34. 
This  sketch  was  made  from  a  case  as  found  in  a  young'  man, 
about  twenty  years  okl,  who  gave  a  histoi"y  of  hernia  existing 
only  one  or  two  years.  The  tunica  vaginalis  had  completely 
closed,  above  the  testicle,  and  probably  had  partially  closed  at 
the  internal  ring.  When  hernia  occurred  the  upper  closure 
was  dilated  and  the  hernia  then  dropped  at  once  to  the  top  of 


THE  HERNIAL  SAC.  75 

the  testicle.  Shortly  after  this  the  cyst  developed  in  front  of 
the  testicle.  The  closure  of  the  tunica  vaginalis  may  be  com- 
plete at  the  internal  ring-,  but  nowhere  else,  leaving  a  capacious, 
serous-lined  sac  in  front  of  the  cord  and  testicle.  Behind  this 
may  descend  a  new  sac  forming  what  has  been  termed  infantile 
hernia  (fig.  35). 

Fig.  2,2. 


J 


Hernia  in  the  funicular  portion  of  tlif  tunica  vaginalis.    {Afacready.) 

It  is  especially  important  to  keep  this  complication  in 
mind  as,  on  opening  the  tunica  vaginalis,  it  might  easily  be  mis- 
taken for  the  hernial  sac  and  the  latter  overlooked  entirely.  One 
should  always  assure  himself  that  the  serous  sac,  into  which 
he  has  opened,  has  communication  with  the  abdominal  cavity. 

These  serous-lined  cavities  are  sometimes  very  perplexing, 
when  found  in  unusual  situations,  and  are  not  easily  accounted 
for.  In  one  of  mv  own  cases,  a  man  40  years  old.  I  found  such 
a  cavitv  entirelv  disconnected,  with  the  cord  or  true  hernial  sac 


76 


ABDOMINAL  HERNIA. 


at  the  inner  side  of  the  cord  and  above  the  pubic  bone,  in  a 
position  that  at  first  led  me  to  beheve  I  had  opened  the  bladder 
wall.  The  most  careful  investigation  failed  to  demonstrate 
communication  with  any  other  cavity.  It  was  a  serous-lined 
cavity  capable  of  containing  about  one  ounce  of  fluid,  empty, 
and  was  removed  from  the  subperitoneal  fat  in  which  it  seemed 
imbedded.  The  testicle  was  in  its  normal  position  in  the 
scrotum.      It  is  quite  possible  that  these  cysts  may  sometimes 

Fig.  34. 


Hernia  into  the  funicular  portion  of  the  tunica  vaginalis,  with  cyst  below.     Age,  20  years. 


arise  from  a  hernial  sac  that  has  become  occluded  at  its  neck 
from  truss  pressure  or  other  causes.  I  have  found  similar  con- 
ditions in  at  least  two  femoral  herni?e. 

In  the  case  shown  in  fig.  36  the  shape  of  the  sac  resembled 
that  of  a  large  mitten,  and  the  diverticula  corresponding  with 
the  thumb  was  full  of  small  intestine.  A  sac  may  vary  in  size 
from  that  of  a  hickory-nut  to  an  enormous  pouch,  reaching  to 
the  knee-joint.  I  have  removed  a  number  of  sacs  large  enough 
to  have  slipped  completely  over  the  patient's  head.  A  sac  may 
form  in  a  lateral  direction  if  its  descent  is  obstructed,  or,  if 


THE  HERNIAL  SAC. 


77 


already  formed  and  its  contents  are  prevented  from  entering  it 
freely,  it  may  expand  between  the  fascial  layers  of  the 
abdominal  wall,  forming  interstitial  hernia  (fig.  37).  Several 
illustrations  of  this  have  been  seen,  where  the  condition  was 
considered  due  to  the  wearing  of  strong  truss  pressure  upon  the 
pubic  bone,  instead  of  retaining  the  hernia  within  the  internal 
rine. 


Fig. 


Infantile  sac.     A,  Irue  hernial  sac.     B,  Tunica  vaginalis,  closed  sac.     C,  Cord.     D,  Testicle. 


Coverings  of  the  Sac. — .\  classical  description  of  the 
formation  and  coverings  might  be  as  follows  :  First,  the  pocket- 
ing into  the  upper  part  of  the  canal  of  the  peritoneum,  which 
eventually  becomes  the  sac ;  second,  as  this  pushes  forward  it  is 
covered  by  the  transversalis  fascia ;  third,  as  it  passes  down 
through  the  canal,  the  cremaster  muscle;  fourth,  as  it  protrudes 
from  the  external  aljdominal  ring  it  takes  with  it  the  inter- 
columnar  fascia;  fifth,  the  superficial  fascia ;  and  sixth,  the  skin. 
The  minute  description  and  enumeration  of  the  coverings  of 
the  hernial  sac  have  led  to  much  timidity  on  the  part  of  the 
occasional  operator,  or  with  the  physician  who  is  forced  into 


78 


ABDOMINAL  HERNIA. 


an  operation  as  an  urgent  life-saving-  measure.  If  he  refers  to 
his  works  on  anatomy,  his  confusion  becomes  worse  by  the  very 
exact  and  exhaustive  accounts,  properly  given,  of  these  unim- 
portant fascial  layers. 

Again  let  us  follow  the  operator's  knife  and  see  these 
tissues  as  we  see  them  at  the  operating  table.  If  the  hernia  is 
direct,  or  complete  oblique,  and  we  cut  down  upon  the  sac,  we 
divide  the   skin   and   its   underlying   fatty   tissue    (superficial 

Fig.  36. 


Showing  sac  shaped  like  a  large  mitten. 


fascia),  and  at  once  see  the  sac  bulging  up  into  the  wound.  It 
is  true  that  this  sac  is  covered  by  a  layer  of  fascia,  containing 
more  or  less  muscular  fibre  and  loose  cellular  tissue,  so  blended 
together  as  to  make  individual  identification  impossible.  It  is 
easily  cleared  from  the  sac  surface  by  blunt  dissection.  Fre- 
quently it  is  so  thin  as  to  allow  the  sac  to  show  plainly  through 
it.  It  is  composed  of  the  transversalis  fascia  and  the  cremaster 
muscle,  and  possibly  the  intercolumnar  fascia.  If  we  are  deal- 
ing with  an  incomplete  ol3lic[ue  inguinal  hernia,  we  will  not  see 
the  sac  until  we  have  split  the  aponeurosis  of  the  external 


THE  HERNIiVL  SAC.  79 

oblique.  In  the  accompanying  diagrammatic  sketch  (fig.  38) 
I  have  attempted  to  show  the  relative  thickness  of  the  cov- 
erings of  the  hernial  sac,  and  a  glance  at  that  will  indicate 
at  once  what  a  small  part  these  two  or  three  layers  of  fascia 
form. 

In  the  shape,  formation,  and  direction  in  which  tlie  hernia 
may  develoj),  these  fasciae  not  infrequently  play  an  important 
part,  but  I  am  now  speaking  from  a  purely  operative  stand- 
point and  the  exaggerated  idea  of  their  importance  in  the  mind 
of  the  young  man,  and  the  medical  man  who  at  times  must,  in 
justice  to  his  patient,  do  surgical  work  and  do  it  promptly. 

Fig.  37. 


Formation  of  an  interstitial  sac.     A,  Peritoneal   cavity.     B,   True  hernial  sac.    C,   Inter- 
stitial sac. 

Only  those  wdio  have  taught  hernia  work  to  the  practitioner  can 
fully  realize  how  often  competent  men  hesitate  to  do  the  right 
thing  at  the  right  moment,  because  of  their  confused  ideas  of 
the  anatomy  of  the  parts,  and  consequently  their  excessive 
dread  of  approaching  them  surgically.  It  is  to  such  men  that 
I  am  trying  to  make  this  subject  more  clear;  not  encouraging 
incompetent  men  to  do  surgical  work;  far  from  it,  but  trying  to 
lighten  the  biu'den  of  the  conscientious  practitioner  who  is 
striving  to  do  his  best  as  a  conservator  of  human  life. 

Contents  of  Sac. — As  this  work  is  not  historical  it  cannot 
enter  very  fully  into  an  account  of  all  the  many  unexpected 
things  that  have  been  found  in  the  hernial  sac.     As  has  been 


80 


ABDOMINAL  HERNIA. 


previously  stated  all  of  the  movable  organs  of  the  interior  of 
the  abdomen  are  found  in  it.  On  account  of  its  longer  mesen- 
tery the  small  intestine  is  most  frequently  met  with.  Next  in 
frequency,  if  not  fully  equalling  it,  is  the  omentum.  The  large 
intestine  may  have  a  long  enough  mesentery  to  allow  it  to 
freel)^  occupy  the  hernial  sac.  The  appendix  and  crecum  are 
many  times  found  in  right  side  hernije,  and  while  it  has  not 
occurred  in  my  own  experience,  my  associate,  Dr.  George  E. 
Doty,  has  found  an  appendix  in  a  left-side  inguinal  hernia, 
showing  the  extreme  lengthening  of  the  mesentery  in  some 

Fig.  7.8. 


Skin. 
Subcutaneous  fat. 

Three  fascial  layers: 

A,  Intercolumnar 
fascia. 

B,  Cremasteric  fascia. 

C,  Tran.sversalis 
fascia. 


Sac. 


Showing  relative  thickness  of  tissues  covering  complete  inguinal  sac. 


people.  The  ovary  and  tubes  are  often  found,  and  the  uterus, 
pregnant  or  otherwise,  has  been  recorded  as  found  in  a  number 
of  cases.  As  early  as  i6iO,  Trautmann  did  a  Ccxsarean  section 
upon  an  incarcerated  uterus  and  succeeded  in  saving  both 
the  mother  and  child. 

The  stomach,  liver,  gall-bladder,  spleen,  pancreas,  and 
kidney,  have  all  been  reported  as  found  in  inguinal  sacs,  as  well 
as  concretions  of  various  shapes  and  sizes.  In  the  case  shown 
in  the  photograph,  fig.  i8,  I  found  at  the  time  of  the  opera- 
tion a  perfectly  round  ball  the  size  of  a  ping-pong  ball,  free  in 
the  sac.     It  was  white  and  had  a  smooth  exterior.     It  could  be 


THE  HERNIAL  SAC.  81 

easily  cut,  ho\\e\'er,  aiul  doubtless  originated  from  a  piece  of 
omentum  which  had  been  separated  from  the  larger  mass,  or 
from  a  h}-pcrtropliie(l  appendix  cpiphjica,  which  had  finally  cast 
loose  fr<jm  the  intestine  and  drcjpped  to  the  bottom  of  the  sac. 
The  patient  had  himself  been  aware  of  its  presence  for  several 
years. 

The  contents  of  a  sac  in  an  ordinary  hernia,  however,  is 
almost  always  either  intestine,  omentum,  or  both  together. 
Large  sacs  almost  always  contain  a  certain  amount  of  fluid 
also.  The  fluid  found  in  a  reducible  hernia  is  usually  light, 
straw-colored,  and  clear.  That  found  in  the  sac  of  a  strangu- 
lated hernia  may  vary  in  color  from  a  light  colTee-color  to  that 
of  a  dark,  heavy  chocolate,  according  to  the  length  of  time  the 
strangulation  has  existed  and  the  intensity  of  the  constriction. 
The  bladder  has  been  mentioned  as  having  been  found  in  a 
hernial  sac.  and  while  protrusion  of  this  organ,  through  the 
internal  inguinal  ring,  is  not  uncommon,  it  is  more  frequently 
found  In'  the  side  of  the  hernial  sac,  uncovered  by  peritoneum, 
than  in  its  interior. 


CHAPTER  VI 

SYMPTOMS  AND  DIAGNOSIS  OF  INGUINAL 
HERNIA. 

REDUCIBILITY  OF  NON-STRANGULATED  INGUINAL  HERNIA. 

Hernia  is  seldom  irreducible  from  its  inception,  but  almost 
always  becomes  so  as  the  result  of  neglect,  producing  one  of  the 
following  conditions:  (a)  Gradual  protrusion  through  a  small 
canal  until  the  bulk  of  the  mass  prevents  its  reduction,  (b) 
Adhesions  of  protruding  contents  to  sac  walls,  or  bands  within 
sac.      (c)    Hypertrophy  of  protruding  omentum. 

(a)  Hernise  named  under  the  first  heading  are  not  neces- 
sarily irreducible,  as  by  confinement  to  bed  and  repeated 
manipulation  they  frequently  can  be  returned  to  the  abdomen. 
This  was  illustrated  in  a  series  of  cases,  reported  before  the 
New  York  Academy  of  Medicine,  by  the  author  a  number  of 
years  since.  The  subsequent  histories  of  these  very  cases,  how- 
ever, proved  conclusively  that  it  was  not  an  advisable  proced- 
ure, as  several  of  them  furnished  emergency  operations  by  the 
recurrence  of  the  protrusion  (in  some  instances,  several  months 
afterwards)  with  symptoms  of  strangulation,  notwithstanding 
the  fact  that  careful  truss-fitting  had  been  carried  out.  It  is 
best,  therefore,  to  consider  and  treat  these  as  cases  of  irreducible 
hernia. 

(b)  Adhesions  of  omentum  to  the  sac  wall  are  verv  com- 
mon in  inguinal  hernia,  but  it  is  rather  rare  to  find  the  bowel 
adherent.  This  is  doubtless  due  to  the  sluggish  character  of 
the  former,  and  the  peristaltic  action  of  the  latter.  In  very  old 
and  large  hernire,  the  normal  motion  of  the  bowel  may  be  lost, 
and  then  adhesions  form.  Such  cases  are  subject  to  the  most 
obstinate  constipation,  terminating  in  true  intestinal  obstruc- 
tion, and  this  is  (|uite  liable  to  cause  death  from  ]:)aralysis  of  the 
bowel  even  if  operation  is  done.     In  these  hernias,  Ijands  of 

82 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


83 


connectixe  tissue  may  also  be  found  running  in  various  direc- 
tions tliroug-h  the  sac,  effectually  preventing  the  return  of  its 
contents. 

(c)   A  very  common  cause  of  the  irreducibility  of  hernia 
is  the  hypertrophy  and  growth  of  protruding  omentum.     It 


Fig.  39. 


Left  scrotal  oblique  inguinal  hernia  containing  large  mass  of  irreducible  omentum. 

becomes  hard,  nodular,  and  of  such  size  that  it  is  impossible  to 
pass  it  back  through  the  canal  even  though  no  adhesions  are 
present.  It  rarelv  happens  that  these  masses,  of  protruding 
omentum,  plug  up  the  canal  so  that  the  intestine  cannot  pro- 
trude. On  the  contrary,  such  cases  are  always  attended  by 
increased  dangers  of  strangulation. 


84 


ABDOMINAL  HERNIA. 


Fig.  39  shows  an  irreducible  hernia  where  a  large  mass 
of  hypertrophied  omentum  was  found  at  time  of  operation. 
Fig.  40  shows  an  even  larger  hernia  when  the  contents  were 
mostly  intestine  and  wholly  reducible. 

Methods  of  Examination. — Inspection  should  be  with  the 
patient  standing,  and  if  a  truss  or  support  is  being  worn,  it 

Fig.  40. 


Enormous  left  scrota   hernia  in  man  of  60  years.     Note  testicle  at  bottom  of  tumor,  showing 
tliat  hernia  is  not  of  the  congenital  type. 


should  be  removed.  By  this  we  will  gain  an  accurate  idea  of 
the  size  and  shape  of  the  tumor,  which  will  be  a  great  aid  in 
diagnosis.  If  nothing  is  seen  but  a  small  bulging  in  the 
vicinity  of  the  internal  ring  with  no  history  of  larger  swelling, 
make  sudden  pressure  over  the  upper  part  of  the  canal  with 
the  ends  of  the  fingers  and  if  something  is  felt  to  slip  back  into 
the  abdomen,  we  may  safely  conclude  that  we  have  to  deal  with 


DIAGNOSIS  OF  INGUINAL  HERNIA.  85 

an  incomplete  inguinal  hernia.  If  the  swelling  extends  outside 
the  external  abdominal  ring,  and  it  is  oblong  in  shape  and 
reducible,  it  is  probable  that  the  case  is  one  of  complete  oblique 
inguinal  hernia;  its  reducibility,  however,  may  not  be  ascertain- 
able until  the  patient  has  been  placed  in  the  recumbent  position. 
On  inspection  it  may  be  seen  that  the  swelling  is  circular  in 
form  and  stands  out  from  the  body  without  much,  if  any,  ten- 
dency to  follow  the  cord,  and  this  would  indicate  a  direct 
inguinal  hernia.  If,  on  the  contrary,  it  has  already  dropped  into 
the  scrotum,  we  may  be  certain  it  is  an  oblique  inguinal  hernia, 
and  is  either  congenital  or  acquired.  If  congenital,  and  the 
hernia  is  protruding,  the  location  of  the  testicle  is  obscured.  If 
the  swelling  is  reducible,  there  will  be  found  an  amount  of  thick- 
ening of  the  tissues,  about  the  cord,  that  does  not  exist  normally. 
If  the  photographs  are  carefully  examined  it  will  be  readily  seen 
that  all  congenital  hernise  present  a  swelling,  uniform  in  shape, 
and  usually  with  a  comparatively  small  neck,  while  in  those  with 
the  acquired  sac,  no  matter  how  large  they  may  be,  the  location 
of  the  testicle  is  plainly  visible.  This  absence  of  testicle  is  also 
noticeable  in  Sigmoid  and  Caecal  hernia,  but  it  will  be  seen  that 
these  hernise  are  frequently  quite  different  from  any  of  the 
other  forms. 

Palpation. — The  feeling  of  a  swelling  carries  with  it  many 
valuable  suggestions  as  to  whether  it  is  hard,  nodular,  and  per- 
haps irreducible,  indicating  adherent  and  hypertrophied  omen- 
tum, or  smooth  in  outline,  fluctuating  and  elastic,  as  in  a  fluid 
cyst.  The  pressure  of  the  fingers  on  the  tumor  may  produce 
the  "  gurgling  "  of  gas  in  the  intestine,  so  characteristic  of 
bowel  protrusion. 

Under  this  heading  may  be  noticed,  also,  the  character  of 
impulse  on  having  the  patient  cough,  to  note  whether  it  gives 
the  impression  of  merely  pushing  the  tumor  forward  without 
expansion.  It  must  not  be  forgotten  that  in  an  abdominal 
varix,  or  large  varicocele,  there  is  upon  coughing  a  thrill  in  the 
enlarged  vessel  that  might  easily  be  mistaken  for  impulse.  This 
holds  equally  true  of  a  partially  filled  fluid  cyst.     It  is  also  true 


86  ABDOMINAL  HERNIA. 

that  many  people  who  have  no  hernia  and  perhaps  Httle  ten- 
dency to  it,  have  a  decided  impulse  on  coughing;  it  is,  however, 
projectile  and  not  expansible  impulse.  In  view  of  all  these 
facts  as  an  indication  of  hernia,  impulse  is  not  considered  of 
great  importance  even  though  it  is  given  a  prominent  place  by 
almost  every  writer  on  hernia.  In  my  own  work,  both  public 
and  private,  I  have  placed  little  reliance  on  it. 

I  desire  to  suggest  here  an  excellent  diagnostic  test  which 
I  have  used  and  taught  for  many  years.  While  the  patient  is 
standing  and  with  the  tumor  at  its  largest  size,  the  fingers  of 
one  hand  are  held  firmly  over  the  inguinal  canal,  maintaining 
firm  pressure  while  he  lies  down.  Gentle  pressure  may  now 
be  made  on  the  tumor  by  the  unoccupied  hand.  It  is  usually 
not  difficult  to  distinguish  the  character  of  the  contents  of  the 
tumor  as  they  pass  under  the  fingers  which  still  compress  the 
canal.  The  rush  of  fluid,  the  nodular,  irregular  feeling  of 
omentum,  or  the  ''  gurgling  "  of  gas  in  the  bowel,  all  tell  their 
own  stol-}^ 

The  tumor  having  been  entirely  reduced,  reverse  this  test 
by  supporting  the  canal  while  the  patient  gets  on  his  feet. 
After  standing  for  a  time,  fluid  will  gradually  pass  the  sup- 
porting fingers,  but  omentum  or  bowel  will  be  retained.  This 
is  a  diagnostic  test,  and  indicates  just  what  will  occur  in  the 
mechanical  treatment  of  these  cases,  i.e.,  that  fluid  cannot  be 
retained  by  external  support. 

Percussion  aids  materially  in  deciding  between  the  solid 
character  of  omentum  with  its  flat  note,  and  the  resonant  note 
given  off  by  gas  imprisoned  in  protruding  bowel. 

Invagination  of  scrotal  tissue,  upon  the  finger  (fig.  41),  is 
a  method  that  needs  more  condemnation  than  praise,  and  I  have 
repeatedly  cautioned  my  classes  against  its  indiscriminate  use. 
It  is  useful  and  allowable  in  large  hernije  in  order  to  decide 
whether  it  is  perfectly  reducible,  but  its  use  on  a  person  suf- 
fering from  a  small  complete  or  an  incomplete  hernia  in  this 
way  is  an  injustice  and  of  little  benefit  to  the  examiner.  By 
forcing  the  finger  up  into  the  external  abdominal  ring,  that 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


87 


aperture  is  certainly  enlarged,  and  but  little  real  information  is 
obtained.  It  is  no  uncommon  thing  to  find  people  with  very 
large  external  abdominal  rings  ,who  have  no  hernia,  and  some 
of  those  who  have  it  of  moderate  size  have  comparatively  small 
rings.  In  my  clinic  at  the  New  York  Post-Graduate  Medical 
School  I  have  had,  within  the  i)ast  ten  years,  three  men  tell  me 

Fig.  41. 


The  method  of  examining  hernia  here  shown— passing  the  finger  into  the  canal  by  invagi- 
nating  the  scrotal  tissues — cannot  be  too  strongly  condemned. 


tliat  they  had  hernia  produced  in  just  this  way,  in  order  to 
avoid  military  service  in  Germany.  Two  of  these  men  had 
employed  a  woman  who  seemed  to  be  an  adept  at  it.  The 
usual  time  required  to  produce  a  noticeable  hernia  was  three 
days,  and  it  was  accomplished  by  dilating  the  inguinal  canal 
with  the  finger  invaginated  in  the  scrotal  tissues,  following  the 
cord  as  a  o-nide. 


88  ABDOMINAL  HERNIA. 

Indigestion,  constipation,  and  prostration  are  results,  and 
therefore  symptoms,  of  hernia  more  frequently  than  generally 
supposed.  It  has  been  no  uncommon  experience  to  see  cases 
that  persistently  resisted  drug  treatment,  entirely  cured  of 
obscure  intestinal  troubles  by  the  perfect  retention  of  hernia. 
AMiile  constipation  is  undoubtedly  more  frequently  a  cause,  it 
is,  in  large  and  uncontrollable  hernise,  a  most  common  and 
dangerous  result.  It  indicates  a  paralysis  of  the  protruding 
bowel  which,  if  not  heeded,  will  result  in  intestinal  obstruction 
that  has  hitherto  proven  beyond  medical  or  surgical  skill  to 
relieve.  There  is  also  an  amount  of  prostration  present  in 
many  of  these  cases  that  is  wholly  disproportionate  to  the 
degree  of  departure  from  a  normal  condition.  The  effect  of  an 
unretained  hernia  upon  men  has  been  compared  with  that  pro- 
duced upon  women  by  some  uterine  derangement  that  may  in 
itself  be  trifling.  The  mental  effect  is  sometimes  very  serious 
and  should  be  promptly  counteracted  by  the  physician.  Three 
cases  of  suicide,  the  impulse  having  its  direct  origin  in  existing 
hernia,  are  within  the  personal  knowledge  of  the  author. 

Pain. — In  by  far  the  greater  number  of  cases,  the  first 
indication  of  hernia  is  in  the  presence  of  a  swelling.  This  may 
be  discovered  by  the  patient  when  it  is  only  a  slight  bulging, 
but  it  is  no  uncommon  thing  to  have  him  come  with  swelling  as 
large  as  an  egg  or  orange,  which  unquestionably  has  been  of 
slow  growth  and  still  has  not  been  noticed.  Naturally  he  as- 
sumes that  it  has  just  occurred  and  gives  a  history  that  is  mis- 
leading. It  proves  conclusively,  however,  that  hernia  may 
reach  considerable  proportions  without  sufficient  pain  to  call 
the  ]3atient's  attention  to  the  parts. 

If  the  development  of  hernia  is  rapid  and  from  violence, 
it  may  be  attended  by  a  certain  amount  of  pain,  but  under  or- 
dinary conditions  this  is  unusual.  There  is  sometimes  a  smart- 
ing or  burning  sensation  in  the  inguinal  region,  and  this  is  very 
liable  to  be  present  in  omental  protrusion.  It  is  believed  that 
those  patients  who  complain  of  extreme  sensitiveness  and  pain, 
should  be  looked  upon  as  suspicious  and  doubtful  cases,  so  far 


DIAGNOSIS  OF  INGUINAL  HP:RNIA. 


89 


as  diagnosis  of  hernia  is  concerned.  If  hernia  really  exists, 
other  troubles  are  also  liable  to  be  found ;  as  an  inflamed  cyst 
on  the  cord,  an  inilammation  of  the  cord  itself,  or  jjossibly  an 
acute  adenitis  of  the  inguinal  glands.  Sometimes  a  burning 
sensation  is  complained  of  as  occurring  late  in  the  day  and  dis- 
appearing during  the  night.     It  is  more  common,  however,  for 

Fig.  42. 


Enormous  irreducible  left  scrotal  hernia,  20  years'  duration,  no  treatment.    Age,  45  years. 
Notice  testicle  at  bottom  of  scrotum,  showing  that  it  is  an  acquired  sac. 


the  patient  to  complain  of  weakness,  or  dragging  pain,  in  the 
lower  part  of  the  abdomen,  worse  at  night  and  better  in  the 
morning,  which  is  increased  while  straining  at  stool,  sneez- 
ing, or  coughing.  Almost  all  writers  on  the  subject  agree 
that  it  seldom  happens  that  hernia  of  goodly  proportions  de- 
velops suddenly,  except  in  the  congenital  type  where  the  sac  is 
already  formed.     In  the  latter  cases,  when  the  neck  of  the  sac 


90 


ABDOMINAL  HERNIA. 


is  sufficiently  dilated,  a  good-sized  hernia  may  drop  at  once 
into  the  pouch  that  awaits  it. 

Swelling. — The  swelling,  which  to  the  patient  may  be  the 
first  indication  of  hernia,  usually  disappears  when  he  is  in  the 
recumbent  position  at  night,  and  may  not  return  the  next  day 
until  he  has  been  on  his  feet  several  hours,  or  it  may  return 

Fig.  43. 


Showing  large  scrotal  hernia  with  true  peritoneal  sac;  outlines  of  testicle  well  defined  on 

the  same  side. 


as  soon  as  he  gets  out  of  bed.  When  it  is  well  developed  it  is 
quite  certain  to  drop  into  its  sac  as  soon  as  he  is  in  an  upright 
position.  Such  a  swelling  is  probably  a  reducible  hernia.  If 
neglected,  the  neck  of  the  sac  and  the  tissues  surrounding  it 
become  more  and  more  dilated,  allr)wing  the  hernia  to  increase 
in  size  until  it  attains  proportions  that  are  truly  enormous,  and 
the  patient  becomes  a  burden  to  himself  and  friends  (see  figs. 
18,  19,  42  and  43). 


DIAGNOSIS  OF  INGUINAL  HERNIA.  91 

At  any  stage  of  tlie  development  of  hernia  there  are  com- 
phcations,  that  may  occur,  that  materially  change  the  character 
of  the  case.  The  first  and  most  dangerous  is,  that  such  an 
amount  of  protruding  viscera  may  be  forced  into  the  narrow 
neck  of  the  sac  that  strangulation  of  the  parts  occurs.  Not 
only  are  the  contents  of  the  intestine  prevented  from  passing 
through  the  protruding  loop,  but  the  circulation  of  blood  is  at 
first  retarded,  then  checked  entirely,  producing  ultimately 
gangrene  of  the  parts.  The  second  change  that  may  alter  the 
swelling  in  character  is  in  the  contents  of  the  sac  becoming 
adherent  to  the  sac  wall,  and  it  is  then  an  irreducible  hernia. 
Irreducible  hernia  is  one  step  farther  away  from  the  normal 
condition  and  increases  its  dangers  to  the  patient  as  well  as  add- 
ing materially  to  the  difficulties  of  treatment. 

DIFFERENTIAL    DIAGNOSIS. 

The  differential  diagnosis  between  types  of  inguinal 
hernias  is  usually  not  attended  by  much  uncertainty  in  uncom- 
plicated cases.  The  manner  of  formation,  size,  and  shape,  all  aid 
in  deciding  whether  we  have  to  deal  with  an  incomplete,  com- 
plete, or  scrotal  hernia,  of  the  oblique  inguinal  type ;  with  a 
sigmoid,  CcTcal,  or  ordinary  direct  hernia. 

Congenital  Hernia. — Perhaps  more  frequently  than  any 
other  type,  we  are  called  upon  to  differentiate  between  the 
congenital  and  acquired  forms  of  inguinal  hernia,  and  if  we 
are  dealing  with  infants  and  children,  and  especially  if  we  hope 
to  cure  them  without  operation,  it  is  quite  important  that  we 
should  recognize  the  difference.  Congenital  hernia  is  always 
of  the  complete  oblique  form,  as  after  passing  through  the  canal 
and  out  at  the  external  abdominal  ring,  it  drops  immediately  in- 
to the  -scrotum  in  front  of  the  testicle.  If  the  congenital  sac  is 
in  the  female,  it  comes  well  down  into  the  labium  majora.  Its 
history  is  usually  of  sudden  formation  and  in  the  male  is  first 
seen  in  the  scrotum.  The  mother  of  the  child  will  tell  you  that 
she  saw  the  swelling  in  the  scrotum  first,  which  means  that  in 
all  probabilitv  it  is  a  congenital  hernia.      If  she  gives  a  history 


92 


ABDOMINAL  HERNIA. 


of  seeing  the  swelling  at  the  external  ring  for  some  days  before 
it  descended  lower,  it  indicates  that  the  hernia  is  of  acquired 
type.  In  the  swelling  produced  by  congenital  hernia  the  loca- 
tion of  the  testicle  is  always  obscure,  and  if  search  is  made  for 
it,  usually  it  will  be  found  at  the  back  part  of  the  scrotum.  The 
swelling  which  includes  the  testicle  is  smooth  in  its  outlines  as 

Fig.  44. 


Typical  congenital  protrusion  111  adult.      Note  that  localion  ul  testicle  cannot  be  seen. 


shown  in  figs.  44  and  45.  By  comparing  these  with  the 
photographs  of  the  other  large  hernice  it  will  be  seen  that,  in 
the  latter,  the  testicle  can  always  be  located.  In  the  case  shown 
in  fig.  46  a  mistake  in  diagnosis  was  made  by  the  family 
physician,  who  supposed  it  to  be  an  ordinary  hydrocele,  and, 
not  having  a  trocar  at  hand,  incised  both  sides  with  a  scalpel. 
It  is  rather  remarkable  that,  after  cutting  into  one.  he  .should 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


93 


then  lia\e  opened  tlie  opposite  side.      Jn  the  latter  instance.  i)n)- 
truchnq-  intestine  con\inced  him  of  the  true  con(Htion,  and  he 

Fig.   45. 


Boy  614  years  old.     Double  congenital  hernia.     Delayed  testicle  on  right.     Both  testicles 
placed  in  scrotum  and  herniae  cured  by  operation. 


Fig.  46. 


Double  congenital  hernia  mistaken  and  incised  for  hydrocele  by  family  jihysician. 

closed  the  wounds  with  plaster.     The  child  was  quite  sick  fol- 
lowing- this,  but  recovered.     It  was  several  weeks  later  that 


94 


ABDOMINAL  HERNIA. 


I  saw  the  case,  but  the  scars  were  distinctly  visible  and  they 
show  faintly  in  the  photograph.  As  the  child's  hernise  were 
reducible,  a  truss  (fig.  47)  was  applied  and  worn  for  one  year, 
at  which  time  he  was  cured  by  operation.  Fig.  48  shows  the 
same  boy  two  years  after  the  operation. 

The  shape  of  a  congenital  hernia  should  ordinarily  sug- 
gest its  diagnosis,  its  size  usually  being  very  large  in  proportion 

Fig.  47. 


Same  case  as  Fig.  46,  showing  herniae   retained   by  truss,  which  was  worn  one  year 
before  operation    for  cure. 


to  the  size  of  the  neck  of  the  tumor.  If  these  herniae  have 
become  \ery  large  and  are  of  long  duration,  this  does  not 
always  hold  true.  Fig.  44  shows  typical  congenital  hernia  as 
seen  in  the  adult.  Compare  with  fig.  49,  which  shows  a 
typical  scrotal  hernia  of  the  acquired  form ;  fig.  50  shows  a 
typical  labial  hernia  in  the  female. 

Oblique   Inguinal   Hernia,   Acquired. — While   congenital 
hernia  \\ill  always  jiresent  itself  as  a  scrotal  protrusion,  tlie 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


95 


acquired  form  may  be  found  as  a  small  bulging  into  tbe  upper 
part  of  the  canal,  or  from  this  t(j  any  degree  of  development  up 
to  the  enormous  protrusions  already  shown.  Even  in  the  latter 
it  will  be  noticed  that  the  testicle  can  almost  always  be  located 
by  inspection.  The  shape  of  oblique  hernia  that  has  not  passed 
into  the  scrotum,  is  oblong,  and  its  presence  in  the  canal  can 
usually  be  detected. 

Fig.  48. 


Case  shown  in  figs.  46  and  47,  two  years  after  operation  for  cure. 


Cases  are  frequently  seen  where  there  is  a  decided  bulging 
over  the  canal  which  comes  from  the  pushing  forward  of  the 
whole  wall  of  the  abdomen  in  this  region,  but  wdiere  there  is 
no  actual  hernia.  Such  cases  may  require  light  support  for  a 
time,  but  fref[uently  even  this  is  unnecessary.  Certainly  thev 
are  not  in  need  of  operation. 

It  is  in  the  very  earliest  stages  that  diagnosis  is  difficult,  and 
it  is  here  that  the  f(^ll(~)wing  test  has  often  been  of  great  service 
to  the  author  and  his  students.    This  test  is  especially  ajiplicable 


96 


ABDOMINAL  HERNIA. 


in  cases  where  there  is  doubt  in  the  mind  of  the  examiner 
whether  hernia  actually  exists.  Stand  by  the  side  of  the  patient, 
who  shall  also  be  standing,  place  the  fingers  gently  over  the 
canal.  Have  the  patient  cough,  and  notice  first,  whether  there 
is  a  feeling  of  expansion  in  the  bulging  part ;  then,  without 
changing   the   position    of    the    fingers,    make    sudden,    sharp 

Fig.  49. 


Front.  Side. 

Typical   right   scrotal    hernia   of  acquired   type.      Note   outlines   of    testicle    at    bottom   of 
scrotum  in  front  view. 


pressure  over  the  canal,  and  note  whether  you  feel  anything  slip 
from  beneath  them.  This  pressure  must  be  quick  and  positive  to 
be  effective,  but  must  not  be  roughly  executed.  It  may  be  re- 
peated any  number  of  times,  having  the  patient  cough  before 
each  time,  to  assure  one's  self  the  slipping  is,  or  is  not.  present. 
If  present,  the  diagnosis  of  hernia  is  quite  certain.  Its  absence 
is  not  quite,  but  nearly,  as  positive  evidence  that  it  does  not 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


97 


exist.  In  the  work  of  a  large  clinic  which  must  he  done  rapidly 
and  still  as  accurately  as  possihle,  this  test  has  proven  itself  of 
the  greatest  value. 

Direct  Inguinal  Hernia  presents  a  round  tumor  having  the 
appearance  of  being  nearer  to  the  median  line  than  the  oblique 
form,  and  even  when  quite  large,  stands  abruptly  out  from  the 

Fig.  50. 


N 


Right  labial  hernia  (complete  oblique  inguinal) ,  similar  to  scrotal  hernia  in  the  male. 

body  without  much  tendency  to  follow  the  cord  (figs.  21  and 
22).  Coming  out  to  the  inner  side  of  the  deep  epigastric  artery, 
it  protrudes  directly  through  the  external  abdominal  ring.  The 
cord  is  at  its  outer  side  from  the  median  line,  and  its  covering 
of  intercolumnar  fascia  prevents  its  descent  into  the  scrotum. 
When  small,  it  can  usually  be  easily  reduced  by  the  pressure  of 
the  hand  with  the  patient  standing.  Its  diagnosis  is  attended 
7 


98 


ABDOMINAL  HERNIA. 


by  less  difficulty  than  in  the  oblique,  but  the  difficulties  of 
operative  work  upon  it  are  greater.  The  rather  common  pres- 
ence of  the  bladder,  either  in  association  with  a  hernial  sac,  or 
alone  as  a  direct  protrusion,  makes  special  caution  necessary. 

In  operating-,  after  the  sac  is  removed,  a  much  more  diffi- 
cult opening  to  close  is  presented  than  in  oblique  hernia,  and 
there  is  a  greater  liability  to  accidental  injury  to  important 
blood  vessels  on  account  of  anatomical  changes  in  the  parts. 

Fig.  51. 


Same  as  Fig.  50.    Four  weeks  after  operation  for  right  labial,  inguinal  hernia. 

Sigmoid  and  Caecal  Hernia  can  properly  be  considered 
under  one  heading  owing  to  their  similarity  in  anatomical  con- 
ditions and  in  general  appearance.  Their  diagnosis  is  particu- 
larly important  owing  to  the  difficulties  in  successfully  and 
safely  operating  upon  them,  and  I  consider  it  fortunate  that  I 
can  present  several  excellent  photographs  of  cases  where  the 
diagnosis  was  confirmed  at  operation.  It  is  not  always  pos- 
sible to  diagnose  this  condition  before  operating,  as  in  cases  of 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


1)9 


bladder  prutrusion,  but  vvc  usually  have  a  peculiar  type  of 
swelling,  and  careful  study  of  the  photographs  presented  will 
make  this  more  clear  than  words  could  (figs.  23,  52,  53, 
54).  Fig  54  shows  both  caecal  and  sigmoid  hernia  in  the  same 
patient,  a  condition  rarely  met  with.  It  will  be  seen  that 
no  matter  what  size  the  tumor  may  be,  its  neck  is  enormously 

Fig.  52. 


Sigmoid  hernia. 

large.  These,  as  well  as  hernia  of  the  bladder,  are  most 
frequently  direct  protrusions,  but  the  latter  never  reaches  the 
enormous  proportions  obtained  by  the  sigmoid-caecal  type.  If 
examined  early,  they  present  the  general  appearance  of  an 
ordinary  direct  hernia.  The  slowness  of  reduction  may  lead 
even  in  their  early  growth,  to  suspect  something  out  of  the 
usual  order.     They  do  not,   like  oblique  inguinal  and  many 


100 


ABDOMINAL  HERNIA. 


cases  of  ordinary  direct  hernia,  slip  back  suddenly  and  with  a 
"  gurgle."  In  truth  their  reduction  is  never  perfect,  as  the 
posterior  wall  of  the  bowel  is  usually  anchored  ouside  of  the 
abdominal  cavity,  but  this  fact  cannot  often  be  ascertained  by 
the  feeling  communicated  through  the  covering  tissues.  The 
reduction  is  accomplished  slowly  and  with  considerable  pain  to 
the  patient.     That  is,  there  is  a  degree  of  sensitiveness  that 

Fig.  53. 


Csecal  hernia. 

seldom  exists  in  other  forms  of  hernia.  It  is  impossible  many 
times  to  decide  between  a  very  much  thickened  sac  and  a 
hernia  that  is  only  partially  reducible. 

There  is  one  other  important  indication  that  may  tell  us 
heiovQ  operation  what  we  are  likely  to  find,  and  that  is,  that 
patients  having  this  form  of  hernia  can  seldom  tolerate  the 
pressure  of  a  truss.  They  frec|uently  abandon  treatment  as 
they   are    far   more   comfortable   without   support,    and   seek 


DIAGNOSIS  OF  INGUINAL  HERNIA.  101 

Fig.  54. 


Sigmoid  and  csecal  hernia  in  tlie  same  patient. 


Fig.  55. 


Woman  75  years  of  age  with  ccecal  hernia.     Much  larger  and  strangulated  when  first  seen. 


102  ABDOMINAL  HERNIA. 

surgical  relief  only  when  the  tumor  becomes  an  intolerable 
burden.  On  account  of  the  large  size  of  the  neck  of  these 
tumors  they  are  not  especially  liable  to  strangulation,  but  gas  is 
frequently  present  in  the  bowel  in  large  quantities,  as  may  be 
easily  demonstrated  by  percussion. 

DIAGNOSIS  OF  OBLIQUE  INGUINAL  HERNIA 
FROM    OTHER    CONDITIONS. 

In  the  consideration  of  this  iDranch  of  the  subject  it  is  well 
to  divide  tumors,  which  are  liable  to  be  mistaken  for  hernia, 
into  the  reducible  and  those  that  are  not  reducible : 

REDUCIBLE    TUMORS.  IRREDUCIBLE   TUTrTORS. 

Hernia.  Hernia. 

Congenital  Hydrocele.  Hydrocele  of  cord. 

V^aricocele  and  Varix.  Hydrocele   of   tunica   vaginalis. 

Partially  descended  testicle.  Partiall}'    descended    testicle. 

Lipoma.  H3ematocele. 

Lipoma. 

[nguinal  x\denitis. 

Impulse  upon  coughing,  which  is  always  referred  to  in 
text-books,  is  in  many  instances  deceptive,  as  a  large  varicocele, 
or  a  partially  filled  fluid  cyst,  may.  give  the  same  sensation. 
Furthermore,  it  will  be  found  that  many  persons  who  are  not 
afflicted  with  hernia  produce  a  strong  impulse  in  the  inguinal 
region  upon  coughing.  It  is  not  the  impulse,  but  expansion 
of  the  tumor  under  strain  of  coughing,  which  furnishes  a  safer 
guide.  When  the  hand  is  placed  over  the  swelling,  the  latter 
will  be  felt  to  expand,  fill  up,  and  increase  in  size,  with  a 
subsequent  contraction  to  its  previous  condition. 

In  the  acquired  variety  of  inguinal  liernia,  when  the  pro- 
trusion has  a  true  peritoneal  covering,  the  swelling  is  usually 
first  noticed  at  the  external  ring,  and  may  vary  in  size  from 
that  of  a  chestnut  to  a  hen's  egg.  It  is  usually  soft,  easily 
compressed,  and  disappears  on  lying  down. 

A  small  tumor  found  in  the  inguinal  region,  presenting 
these  characteristics,  is  pretty  sure  to  be  hernia.     It  must  be 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


103 


borne  in  mind,  however,  that  a  large  Varix,  as  sometimes  seen 
in  pregnant  women,  or  a  liydrocele  of  the  cord  where  the  fluid 
is  partially  reducible  into  the  abdomen  or  into  the  tissues,  will 
closely  resemble  hernia.  Tn  the  case  of  varix,  it  can  usually  be 
differentiated  by  tlic  fact  of  a  general  varicose  condition  of  the 
labia  or,  perhaps,  of  the  entire  leg  of  that  side.  An  excellent 
diagnostic  test  in  all  reducible  tumors  is  as  follows : 


Fig.  56. 


A  left  varicocele  and  femoral  varix  011  same  side.  (Eccles.) 

"While  the  patient  is  standing  and  the  tumor  largest  in  size, 
the  fingers  of  one  hand  are  held  firmly  over  the  inguinal  canal, 
maintaining  firm  pressure  while  the  recumbent  position  is 
assumed.  Gentle  pressure  may  now  be  made  on  the  tumor  by 
the  unoccupied  hand.  It  is  usually  not  difficult  to  distinguish 
the  character  of  the  contents  of  the  tumor  as  they  pass  under 
the  fingers  which  still  compress  the  canal.     The  rush  of  fluid, 


104  ABDOMINAL  HERNIA. 

the  nodular,  irregular  feeling  of  omentum,  or  the  ''  gurgling  " 
of  gas  in  the  bowel  all  tell  their  own  story.  The  tumor  having 
been  entirely  reduced,  reverse  this  test  by  supporting  the  canal 
while  tlie  patient  gets  on  his  feet.  The  fluid  will  then  gradu- 
ally pass  the  supporting  fingers,  but  omentum  or  bowel  will  be 
retained.  This  is  not  only  a  diagnostic  test,  but  indicates  just 
what  will  occur  in  the  mechanical  treatment  of  these  cases,  i.e., 
that  fluid  cannot  be  retained  by  external  support. 

Congenital  Hydrocele  is  reducible  and  forms  the  most 
common  fluid  tumor ;  it  may  be  accompanied  by  a  true  hernial 
protrusion,  making  diagnosis  even  more  obscure.  In  many  of 
these  cases,  diagnosis  can  be  made  only  by  the  action  of  the 
supposed  hernia  under  mechanical  treatment  and  inability  to 
retain  its  fluid  part.  Translucency  and  the  smallness  of  the 
neck  of  the  tumor  must  be  borne  in  mind.  It  usually  reduces 
slowly  and  the  fluid  can  be  felt  rushing  into  the  abdomen  by 
holding  a  finger  over  the  canal,  while  pressure  is  made  from 
below  by  the  other  hand.  It  occurs  almost  exclusively  in  very 
early  life.  If  mistaken  for  hernia  and  treated  as  such,  it  will 
be  a  fortunate  mistake  for  the  patient,  as  it  will  be  cjuite  sure 
to  cure  a  condition  that  later  might  develop  into  hernia.  As  a 
truss  will  not  retain  the  fluid,  it  is  important  to  diagnose  the 
condition  and  enlighten  the  parents  as  to  what  they  may  expect. 
In  some  instances  of  protrusion  into  a  congenital  sac  of  thin 
omentum,  the  tumor  is  quite  elongated  and  has  the  feeling  of 
fluid  contents. 

Varicocele  and  Varix  (figs.  56  and  57),  it  would  seem, 
.should  be  recognized  at  sight,  but  the  fact  that  "patients  have 
been  sent  hundreds  of  miles  for  the  treatment  of  hernia  when 
the  latter  did  not  exist,  proves  that  it  is  not  always  so  plain 
to  the  average  examiner.  The  test  given  for  fluid  tumors, 
carefully  executed,  should  give  conclusive  information. 

The  common  saying  that  a  varicocele  feels  like  a  bunch  of 
earthworms  is  not  in  itself  a  safe  guide,  as  a  mass  of  thin 
omentum  may  convey  very  much  the  same  sensation  and  present 
a  similar  appearance.   It  seems  hardly  pardonable,  however,  that 


DIAGNOSIS  OF  INGUINAL  HERNIA. 


105 


such  a  case  as  that  shown  in  hg.  57,  where  the  dilated  sur- 
face veins  at  once  suggested  its  character,  should  be  mistaken 
for  hernia.  In  some  men,  however,  not  only  does  the  scrotal 
surface  present  a  perfectl}'  normal  condition,  but  the  cord  is 
so  enlarged  in  the  canal  that  it  has  the  feeling  of  hernia. 
Here  again,  if  the  hand  is  placed  over  the  canal  and  the  patient 
made  to  assume  a  lying-down  position,  the  tumor  will  fli sap- 
pear  without  any  part  of  it  having  been  felt  to  pass  under  the 


fingers. 


Fig.  57. 


Extreme  case  <j1  varicocele  that  had  been  mistaken  for  hernia. 

In  a  case  of  double  abdominal  varix  which  had  been  mis- 
taken for  hernia,  sent  to  me  from  a  distant  state,  the  superficial 
epigastric  vein,  on  either  side,  was  so  enormously  dilated  as  to 
simulate  fairly  well  double  inguinal  hernia.  The  tumors  were 
easily  compressible,  which  gave  them  the  appearance  of  being 
reducible,  and  a  truss  had  been  worn  over  them.  They  gave 
the  peculiar  thrill  of  reducible  fluid  tumors  when  the  patient 
coughed,  and  this  had  been  mistaken  for  impulse.  There  were 
no  other  enlarged  veins  in  the  immediate  vicinity,  but  below  the 
knee  the  varicose  condition  was  quite  marked. 


106  ABDOMINAL  HERNIA. 

Labial  Varix  may  be  even  more  misleading  and  is  more 
frequently  met  with.  The  tumor  disappears  almost  completely 
on  lying  down  and  appears  promptly  on  standing  up,  but  it  can 
easily  be  demonstrated  by  the  test  for  fluid  tumors,  already 
given,  that  it  is  not  reducible  to  the  abdomen.  Labial  varix 
occurs  most  frequently  during  pregnancy  and  usually  disap- 
pears soon  after  confinement.  These  cases  simulate  labial 
hernia,  which  is  not  nearly  so  common  in  women  as  scrotal 
hernia  in  men.  The  following  case  was  seen  in  consultation 
(June  2^,  1898)  :  Mrs.  A.,  age  thirty-five  years,  had  been  seen 
by  several  physicians  for  sweUing  in  the  left  labium.  Diagnosis 
of  hernia  had  been  made  by  all,  and  several  different  kinds  of 
trusses  had  been  applied  with  no  effect  except  great  discomfort. 
She  was  five  months  pregnant  and  in  perfect  general  health. 
The  swelling  was  first  noticed  two  months  since  and  gradually 
increased.  It  was  not  attended  by  actual  pain,  but  smarting  and 
burning,  and  she  experienced  a  sense  of  weight  that  was  very 
disagreeable.  It  disappeared  almost  wholly  when  lying  down 
and  returned  promptly  upon  standing. 

A  soft,  compressible  tumor  the  size  of  a  large  goose-egg,  or 
small  orange,  was  found  in  the  left  labium  majora  and  ex- 
tended well  up  towards,  but  not  to,  the  external  ring  on  that 
side.  It  also  extended  up  the  left  vaginal  wall  and  connected 
with  deeper  parts  by  a  cord  nearly  as  large  as  one's  thumb. 
Diagnosis. — Varix  of  veins  of  labia.  Treatment. — Expectant ; 
recumbent  position  for  relief  when  in  pain.  If  trouble  is  ex- 
perienced after  confinement,  obliteration  of  veins  is  advised. 
Letter  from  family  physician  (Jan.  21,  1899)  gives  subsequent 
history  as  follows : 

"  Perhaps  it  might  interest  you  to  learn  the  history  of 
Mrs.  A.  of  this  city,  whom  you  saw  with  Dr.  M.  last  summer, 
and  who  had  a  varicocele  of  the  left  labium  major;  she  was 
also  pregnant.  We  had  supposed  that  she  might  have  a  hernia. 
As  her  pregnancy  progressed  the  tumor  became  smaller,  and  I 
was  able  to  feel  the  varicose  veins.  By  the  time  labor  came  on 
the  tumor  diminished  to  one-half  its  former  size,  was  no  im- 


DIAGNOSIS  OF  INGUINAL  HERNIA.  107 

pediment,  and,  though  forceps  were  used,  she  escaped  without 
injury  to  perineum  or  labium.  It  is  now  four  months  since  her 
baby  was  born,  and  she  makes  no  complaint  of  her  varicocele." 

The  above  letter  illustrates  in  a  graphic  manner  how,  when 
the  pregnant  uterus  left  the  pelvis  as  pregnancy  advanced,  the 
vessels  were  released  from  pressure  and  practically  resumed 
their  normal  size. 

Undescended  Testicle  lying  just  outside  of  the  external 
ring",  easily  reduced  into  the  canal,  but  with  a  cord  too  short  to 
allow  it  to  go  into  the  scrotum,  may  be  misleading.  The  empty 
scrotum  on  that  side  should  direct  attention  to  the  true  condi- 
tion. Furthermore,  by  deep  pressure  over  the  canal  it  will  be 
seen  that  the  reduction  is  not  complete.  Numerous  illustra- 
tions of  this  condition,  in  various  parts  of  this  work,  will 
convey  not  only  a  correct  idea  of  their  appearance,  but  will  also 
indicate  their  very  common  occurrence. 

In  cases  where  apparent  reduction  has  been  accomplished 
and  there  is  still  felt  a  thickening  in  the  canal,  while  the  patient 
is  in  a  recumbent  position,  one  of  the  following  conditions 
should  be  suspected ;  adherent  omentum,  retained  testicle, 
(ovary  if  female),  or  fluid  encysted  ^vithin  the  sheath  of  the 
cord.     Lipoma,  or  loose  fat  in  canal,  might  also  be  mentioned. 

An  abscess,  especially  of  the  slow  forming  variety  seen  in 
cases  of  Pott's  disease,  with  a  long  sinus,  may  prove  very  per- 
plexing w^hen  it  points  in  the  inguinal  region.  Under  moder- 
ate i:)ressure,  with  the  patient  on  his  back,  it  ma}-  be  so  far 
reducible  as  to  give  the  appearance  of  hernia.  The  slowness  of 
reduction,  and  "  boggy "  feeling  should  lead  to  suspicion, 
especially  if  Pott's  disease  is  known  to  exist.  Iliac  abscess  may 
present  a  tumor  in  the  inguinal  region,  but  Psoas  abscess  will 
more  likely  point  in  the  femoral  space. 

Lipoma. — In  the  sense  of  a  true  fatty  tumor  that  forms  in 
the  subperitoneal  fat,  and  from  its  own  size  and  weight  forces 
itself  down  through  the  inguinal  canal,  it  is  not  believed  that 
lipoma  is  very  common.  Elongated  pieces  of  fat  occupying 
the  canal  and  protruding  at  the  external  ring  with  or  without 


108  ABDOMINAL  HERNIA. 

hernia,  are  extremely  common,  and  perhaps  the  most  con- 
venient term  is  to  call  them  lipoma.  It  is  believed  that  they 
are  formed  by  normal  subperitoneal  fat  being  forced  into  the 
canal  under  some  unusual  strain  and  acting  as  a  dilating 
wedge ;  not  only  this,  but  it  pulls  down  a  pocket  of  peritoneum 
which  becomes  a  true  hernial  sac.  The  diagnosis  of  such 
masses  of  fat  from  hernia  is  extremely  difficult  and  often 
impossible.  It  will  be  found,  however,  that  when  a  swelling  of 
this  character  is  reduced  to  the  canal,  it  can  still  be  felt  under 
its  fascial  coverings.  It  does  not  drop  back  suddenly  as  would 
a  piece  of  free  omentum.  Exact  diagnosis  is  not,  however, 
very  important,  as  the  treatment  should  in  any  case  be  the  same 
as  for  hernia.  If  there  is  nothing  but  fat  in  the  canal,  the 
wearing  of  a  truss  for  a  year  may  destroy  it,  and  it  is  in  such 
cases  that  occasionally  we  have  records  of  the  remarkable  cure 
of  hernia,  in  the  adult,  by  truss-wearing.     . 

Irreducible  Tumors  are,  as  a  rule,  more  easily  distin- 
guished from  hernia.  An  acutely  inflamed  inguinal  gland 
should  never  mislead  an  examiner,  as  its  heat,  tenderness,  and 
closeness  to  the  skin,  are  characteristics  which  are  foreign  to 
hernia.  They  are  also  unaccompanied  by  any  of  the  general 
symptoms  found  in  strangulated  hernia. 

Encysted  hydrocele,  and  hydrocele  of  the  cord,  especially 
within  the  canal,  make  diagnosis  uncertain  in  rare  cases.  If 
on  the  cord  lower  down,  they  are  usually  easily  recognized  by 
their  round,  smooth,  elastic  feel,  and  by  their  attachment  to  the 
cord.  Cysts  just  outside  the  ring,  which  may  be  reduced  into 
the  canal,  are  particularly  liable  to  cause  mistake.  Under  truss- 
treatment,  liowever,  they  usually  demonstrate  their  character 
by  tlie  impossibility  of  their  retention.  Furthermore,  when  they 
are  reduced,  they  lift  the  testicle  high  up  in  the  scrotum.  A 
gentleman  came  to  me  a  few  years  since,  who  had  visited  most 
of  the  best-known  truss  makers  in  attempts  t(^  retain  a  small 
swelling  which  protruded  at  the  external  ring.  Recognizing 
its  true  character,  I  drew  off  with  a  small  aspirating  needle 
about  half  an  ounce  of  amber-colored  fluid  and  injected  5  drops 


DIAGNOSIS  OF  INGUINAL  HERNIA.  109 

of  95  per  cent,  pure  phenol.  The  cure  was  complete,  as  no 
hernia  had  ever  been  present. 

Hydrocele  of  the  tunica  vaginalis  should  be  diagnosed 
from  incarcerated  or  irreduciljle  hernia  by  the  fact  that  it  is 
first  discovered  in  the  scrotum  and  enlarges  from  the  bottom 
upwards;  that  the  cord  is  of  normal  size  where  it  passes 
through  the  abdominal  ring,  and  that  the  tumor  is  translucent, 
tense,  and  fluctuating,  and  the  location  of  the  testicle  uncer- 
tain. In  the  beginning  of  hernia  there  is  a  history  of  a 
reducible  tumor,  while  in  hydrocele  there  is  a  history  of  a 
gradual  growth  without  any  period  of  reducibility.  Hemato- 
cele lacks  the  diagnostic  test  of  transmitted  light,  but  has  a 
history  of  traumatism  which  should  guide  us  aright. 

Lipoma  that  are  only  partially  reducible  may  sometimes 
form  in  the  canal  and  slip  through  the  external  ring.  These 
tumors  and  intramuscular  layers  of  loose  fat,  w^ork  their  way 
into  the  canal,  become  elongated  and  protrude.  It  is,  at  times, 
impossible  to  recognize  them  until  the  patient  reaches  the 
operating  table.  As  it  is  always  considered  advisable  to  oper- 
ate, on  account  of  the  certainty  with  which  they  are  followed  by 
hernia,  the  uncertainty  of  diagnosis  is  unimportant. 

The  incomplete  descent  of  the  testicle  forms  a  far  more 
common  complication  than  is  generally  supposed.  If  it  is 
arrested  by  adhesions,  or  shortness  of  its  cord,  in  the  canal  or 
near  the  external  ring,  it  may  make  diagnosis  uncertain  and 
simulate  irreducible  hernia.  Young  men  who  have  this  defect 
are  frequently  very  sensitive  about  it,  feeling  that  they  are 
physically  imperfect,  and  add  to  the  difficulties  of  the  situation 
by  trying  to  disguise  the  fact  that  the  scrotum  is  emptv.  A 
case  of  this  kind  that  had  been  previously  examined  by  two 
physicians,  was  seen  in  consultation  for  supposed  incarcerated 
hernia,  but  proved  to  be  a  post-gonorrhceal  epididymitis  with 
a  testicle  permanently  located  near  the  internal  ring.  The 
patient  had  deluded  the  attending  physicians  by  arranging  and 
persistently  keeping  his  clothing  so  that  the  scrotum  was  not 
exposed.     He  also  assured  me  that  he  had  repeatedly  been 


110  ABDOMINAL  HERNIA. 

fitted  by  truss  makers  without  ever  allowing  them  to  see  the 
scrotum.  Another  case  of  this  type  was  seen  that  had  been 
diagnosed  inflamed  inguinal  gland,  and  an  incision  was  about 
to  be  performed  when  the  true  character  of  the  case  was  dis- 
covered by  finding  one  side  of  the  scrotum  empty. 

In  the  female,  an  ovary  lodged  in  the  inguinal  canal  pre- 
sents a  form  of  complication  resembling,  in  most  features,  that 
of  delayed  testicle.  It  is  as  persistent  as  is  the  testicle,  in 
remaining  outside  the  abdominal  wall.  It  is  not  as  sensitive 
to  pressure  from  truss-wearing,  nor  does  it  seem  so  liable  to 
inflammatory  action.  It  can  seldom  be  fully  replaced  within 
the  abdomen  by  manipulation,  and  even  when  apparently  this 
has  been  done,  it  readily  slips  out  from  under  the  retaining  pad 
of  the  truss  and  may  then  become  quite  painful.  They  are 
almost  always  painful  at  the  menstrual  period.  Ovaries  found 
in  this  position  are  frequently  cystic  and,  in  rare  instances,  de- 
generation of  structure  has  been  so  far  advanced  as  to  warrant 
their  entire  reijioval. 

Cysts  forming  along  the  cord  in  the  male,  or  in  the  canal 
of  Nuck  in  the  female,  may  complicate  the  mechanical  treat- 
ment of  hernia  to  a  moderate  extent,  and  may  be  very  perplex- 
ing in  making  a  correct  diagnosis.  Small  cysts,  when  they 
come  under  truss  pressure,  usually  disappear  after  a  time;  if 
larger,  and  in  the  way,  they  can  be  aspirated.  It  is  when  they 
are  unrecognized  and  attempts  are  made  to  replace  and  retain 
them  within  the  abdomen,  that  they  cause  the  most  trouble. 

Inguinal  Adenitis. — An  inflamed  inguinal  gland  may  form 
one  of  the  complications  of  hernia,  making  diagnosis  obscure, 
as  indicated  by  the  case  of  a  woman  whO'  gave  a  perfectly  clear 
history  of  reducible  inguinal  hernia,  retained  by  truss-wearing 
for  several  years.  At  the  time  of  examination,  she  presented 
a  hard,  slightly  painful  tumor,  in  the  inguinal  region,  which 
could  not  be  reduced.  It  presented,  in  fact,  every  appearance 
of  an  incarcerated  omental  protrusion,  except  that  there  was  a 
suspicious  amount  of  heat  and  tenderness.  Attempts  to  reduce 
the  protrusion  failed,  and  upon  the  points  named  it  was  diag- 


DIAGNOSIS  OF  INGUINAL  HERNIA.  Ill 

nosed  inguinal  adenitis.  This  diagnosis  was  subsequently 
confirmed  by  the  subsidence  of  the  inflammation  and  the  return 
of  her  hernia,  which  was  easily  reducible.  During  the  active 
inflammation  of  the  gland,  hernia  was  prevented  from  entering 
the  canal,  even  when  the  truss  was  temporarily  abandoned. 

I  have  seen  a  case  of  this  kind  that  was  even  more  obscure. 
A  gentleman  who  has  a  large  surgical  practice  in  a  neighbor- 
ing city  brought  to  me  a  healthy,  red-cheeked  young  man  of 
twenty-six  years,  six  feet  tall  and  weighing  nearly  two  hundred 
pounds.  Two  weeks  before  he  had  felt  some  discomfort  in  the 
riglit  inguinal  region  and  shortly  after  discovered  a  small 
swelling.  The  discomfort  had  continued,  but  it  was  not  suf- 
ficient to  keep  him  from  his  occupation.  My  diagnosis  was  an 
inflamed  cyst  in  the  canal  or  an  incarcerated  piece  of  omentum 
surrounded  by  fiuid,  which  commonly  occurs  in  the  latter  con- 
dition. Favoring  especially  the  last-named  diagnosis,  an  opera- 
tion was  advised,  and  the  doctor  invited  me  to  do  it.  My  sur- 
prise was  very  great  when,  on  splitting  the  aponeurosis  of  the 
external  oblicjue  muscle,  I  found  confined  to  the  limits  of  the 
canal  an  abscess  containing  about  half  an  ounce  of  pus.  Care- 
ful examination  convinced  us  that  this  did  not  communicate 
either  w^ith  the  abdominal  cavity  or  with  the  subcutaneous 
parts.  The  young  man  disclaimed  any  venereal  disease,  and 
how  infection  had  taken  place  in  this  unusual  location  we  were 
unable  to  decide.  This  was  not  an  inguinal  adenitis,  but  an 
abscess  zvithin  the  inguinal  canal. 

Sarcoma,  and  even  carcinoma,  of  the  inguinal  gland  must 
be  considered  in  making  a  differential  diagnosis  of  incarcerated 
or  irreducible  hernia.  One  case  sent  to  me  as  irreducible 
inguinal  hernia,  was  sarcoma,  which  later  invaded  the  abdom- 
inal cavity  and  caused  the  death  of  the  patient. 

DIAGNOSIS    OF    FEMORAL    FROM    INGUINAL    HERNIA. 

Ordinarily  this  is  not  in  the  least  difficult,  but  in  some 
instances  may  be  extremely  so.  If  hernia  is  found  in  the 
scrotum   or  labium   it   is   at   once   recognized   as   having  an 


112  ABDOMINAL  HERNIA. 

inguinal  origin.  Femoral  hernia  usually  protrudes  as  a  small, 
circular  swelling,  in  the  femoral  space  just  below  Poupart's 
ligament,  but  it  sometimes  comes  in  contact  with  resistent  tis- 
sues that  turn  it  sharply  upwards,  and  it  then  occupies  almost 
exactly  the  position  of  an  incomplete  inguinal  hernia.  Such  a 
hernia  is  always  reduced  with  difficulty,  and  this  fact  alone, 
occurring  in  a  moderately  small  hernia,  should  lead  us  to  sus- 
pect that  it  is  of  tlie  femoral  variety.  In  addition  to  this, 
however,  is  the  fact  that  reduction  in  femoral  hernia,  especially 
of  the  kind  named,  will  be  downwards  and  backwards,  appar- 
ently directly  into  the  thigh.  As  the  hernia  slips  back  the 
finger  can  usually  follow  it  into  the  aperture  through  which 
it  has  returned.  Pressure  over  the  inguinal  canal  will  also 
demonstrate  the  fact  that  this  is  empty.  A  test  that  I  have 
used  for  many  years  in  doubtful  cases  and  that  has  proven 
valuable,  is  as  follows : 

Locate  the  spine  of  the  pubes  and  place  a  finger  upon  it. 
Then,  by  the  fingers  of  the  other  hand,  locate  the  iliac  spine 
upon  the  crest  of  the  ilium  and  place  a  finger  upon  that.  Now 
draw  an  imaginary  line  between  the  two,  representing 
Poupart's  ligament,  and  if  the  bulk  of  the  tumor  is  below  that 
line  it  is  femoral ;  if  above  it  is  inguinal.  In  this  connection  it 
is  also  well  to  remember  that  the  internal  ring  is  just  half-way 
between  the  spines  upon  which  the  fingers  rest. 

The  pubic  spine  is  an  important  landmark,  complete 
inguinal  hernia  passing  over  the  pubic  bone  between  it  and  the 
median  line,  and  femoral  hernia  always  presenting  outside  and 
below  this  bony  prominence.  It  is  well  to  remember  that 
femoral  hernia  is  A-ery  rare  in  youth  and  childhood,  and  that 
while  it  does  occur  in  the  male,  it  is  far  more  common  in  the 
female. 

PROGNOSIS. 

A  small  reducible  inguinal  hernia  is  not  in  itself  a  serious 
matter,  but  the  fact  that  it  carries  with  it  potentialities  that 
may  at  any  moment  transform  it  into  a  highly  dangerous  con- 
dition, is  sufficient  to  make  it  a  matter  worthy  of  the  most 


DIAGNOSIS  OF  INGUINAL  HERNIA.  113 

earnest  solicitude  on  the  part  of  both  doctor  and  patient.  These 
dangers  increase  vvitii  the  degree  of  development,  and  neglect 
merely  invites  disaster.  It  is  a  condition  that  demands  imme- 
diate attention,  as  its  history  from  earliest  beginnings  is  one 
of  constant  increase  in  size  and  added  complications,  if  allowed 
to  go  unattended.  Sometimes,  though  rarely,  physicians  advise 
mothers  to  allow  their  children  to  outgrow  hernia;  this  is 
wrong  and  due  to  utter  ignorance  oi  the  subject. 

Hernia  has,  until  recently,  been  classed  among  the  incu- 
rable surgical  affections,  but,  fortunately  for  humanity,  it  has 
hnalh'  been  permanently  removed  from  that  list.  There 
remain,  however,  two  forms  of  treatment,  palliative  and 
curative,  and  while  the  physician  may  advise,  the  patient  must 
elect  which  form  is  to  be  used. 

Palliative  treatment  may,  under  certain  conditions,  be  also 
curative,  but  in  by  far  the  greater  number  of  cases  it  is  only 
temporizing,  and  the  patient  is  carrying  with  him  a  degree  of 
danger  that  is  greater  than  that  involved  in  submitting  to 
methods  designed  to  cure  the  affection.  Palliative  methods 
consist  in  the  adjustment  of  retaining  apparatus,  such  as 
trusses.  1)andages,  etc.,  that  prevent  the  protrusion  of  the 
hernia,  and,  while  they  remain  efficient,  protect  the  patient  from 
the  danger  of  strangulated  hernia.  In  very  young-  children 
the  wearing  of  such  apparatus  for  one,  two,  or  more  years 
frequently  produces  a  permanent  cure,  but  in  the  adult  this 
fortunate  result  is  seldom  obtained,  and  they  are  obliged  to 
continue  the  use  of  artificial  support  throughout  life. 

Curative  treatment  consists  in  a  surgical  operation  for  the 
removal  of  abnormal  conditions  and  restoration  of  the  parts  to 
their  normal  strength.  For  many  centuries  it  was  the  oppro- 
brium of  surgery  that  attempts  in  this  direction  not  onlv 
uniformly  failed,  but  were  attended  by  serious  danger.  One 
of  the  greatest  achievements  of  modern  surgery  is  that  not  only 
have  the  dangers  been  almost  wholly  eradicated,  but  that  the 
degree  of  success  attained  is  far  beyond  the  expectations  of  the 
most  hopeful. 


CHAPTER  VII. 

MECHANICAL  TREATMENT  OF  INGUINAL  HERNIA. 

There  can  be  no  question  respecting  the  rapid  advance  in 
the  surgical  treatment  of  hernia  during  the  past  ten  years. 
Operations  for  the  rehef  of  this  defect  have  not  only  become 
comparatively  safe,  but  any  impartial  observer  must  admit  that 
more  cures  are  being  obtained  than  were  formerly  thought 
possible.  The  increased  safety  in  operation  is  unquestionably 
due  to  the  wonderful  advance  made  in  all  branches  of  surgery, 
while  the  increase  in  the  percentage  of  cures  results  not  only 
from  improved  methods,  but  from  the  fact  that  now  many 
cases  of  small  and  recent  hernia  are  being  operated  upon, 
whereas  in  former  years  only  those  cases  considered  desperate 
were  subjected  to  surgical  treatment. 

No  matter  how  much  advance  there  may  be  in  the  art  of 
surgery  and  in  the  cure  of  hernia  by  operative  means,  the 
mechanical  treatment  of  this  affection  must  always  remain  an 
important  source  of  relief  to  a  large  number  of  sufferers. 
Patients  requiring  artificial  support  for  retention  of  hernia 
form  a  great  army  of  sufferers  who  look  to  the  general  prac- 
titioner for  aid.  He  should  not  allow  them  to  drift  about  and 
put  up  with  the  services  of  the  inexperienced  and  non-medical 
truss  seller,  l)ut  take  them  under  his  own  care  and  know  that 
they  are  perfectly  protected  from  the  danger  of  strangulated 
hernia.  The  wearer  of  a  truss  is  a  chronic  invalid,  and  he 
should  submit  himself  to  his  physician,  at  regular  intervals,  for 
inspection  and  the  correction  of  defects  in  the  truss  and  in  the 
manner  of  wearing.  Some  neglected  and  complicated  hernise 
may  demand  the  attention  of  those  who  have  had  large  and 
special  experience,  but  the  prevention  of  this  extreme  condition 
rests  with  the  general  practitioner,  and  he  can  in  all  ordinary 
cases  carry  out  the  necessary  details  for  securing  the  safety  and 
comfort  of  the  patient. 

114 


MECHANICAL  TREATMENT. 


115 


Thirty  years  ago  the  practice  of  that  special  branch  of 
surgery  now  known  as  orthopedic  was  almost  wholly  in  the 
hands  of  instrument  makers  and  "  quacks."  The  crippled  and 
deformed  have  been  rescued  from  the  hands  of  the  ignorant, 

Fir..  58. 


Statuette  found  at  Susa  by  M.  Gouvet  while  exploring  an  ancient  Phoenician  cemetery; 
pronounced  by  M.  Maspero  and  other  Egyptologists  to  be  an  example  of  the  Egyplian 
deity  B^s,  or  Bizou,  and  to  date  back  to  about  the  year  900  b.c.  The  fortunate  owner  is 
Dr.  F.  Poncet,  Cluny,  France.  It  shows  a  truss  applied  to  double  inguinal  hernia,  and  also 
presents  double  femoral  hernia.     (For  full  description  see  Lc  Progrfs  Mrdica/.  June  i,  i^^o.s.) 


and  there  is,  perhaps,  no  more  careful  scientific  surgical  work 
than  that  done  by  the  orthopedist.  Quackery,  undoubtedly,  still 
exists  in  this  line,  but  it  is  not  supported  by  the  wealthy  and 


116  ABDOMINAL  HERNIA. 

intelligent  people  as  in  the  past.  Instrument  makers  construct 
orthopedic  apparatus,  but  they  seldom  either  devise  or  apply 
them.  They  certainly  do  not  treat  the  patient.  For  many 
years  the  author  has  hoped  to  rescue  the  mechanical  treatment 
of  hernia  from  the  hands  of  those  who  know  nothing  of  the 
anatomy,  diagnosis,  or  pathology,  and  therefore  little  of  the 
proper  treatment  of  these  important  cases.  It  was  hoped  that 
orthopedic  surg-eons  would  introduce  mechanical  treatment 
of  hernia  into  their  special  work.  As  one  of  the  founders  of 
the  American  Orthopedic  Association,  he  endeavored  to  con- 
vert his  friends  to  his  views,  but  failed.  No  members  of  the 
profession  are  so  well  educated  to  do  the  mechanical  work  as 
they,  but  now,  since  the  great  advance  in  the  surgical  side  of  the 
subject,  it  is  still  farther  away  from  them. 

This  is  a  misfortune  to  the  large  number  of  truss  wearers 
that  must  always  remain  with  us,  no  matter  what  advance  is 
made  in  surgery,  because  it  leaves  them  in  the  hands  of  those 
who  must  necessarily  do  poor  work  and  make  serious  mistakes, 
no  matter  how  honest  their  intentions  may  be.  Druggists  and 
instrument  makers  should  continue  to  sell  trusses,  but  the  diag- 
nosis of  the  case,  selection  and  application  of  the  truss,  and 
subsequent  care  of  the  patient,  should  be  in  the  hands  of  those 
who  have  been  qualified  by  medical  education  to  fulfil  these 
duties.  These  remarks  are  not  intended  to  reflect  upon  men 
who,  while  they  have  not  had  a  medical  education,  have  from 
many  years'  experience  as  truss  fitters  become  expert  in  this 
line  of  work  and  fairly  accurate  even  in  diagnosis.  Many  of 
these  men  have  taken  the  trouble  to  study  the  anatomy  of  the 
parts  involved  in  hernia.  The  most  serious  charge  that  can  be 
made  against  some  of  them  is,  that  they  frequently  favor  some 
special  style  of  truss,  and  their  expertness,  as  applied,  lies  more 
in  their  ability  to  fit  the  |)atient  to  this  truss  than  in  the  selection 
of  and  fitting  to  him  a  truss  best  suited  to  his  condition. 

History  and  Construction  of  Trusses. — The  wliolesale 
manufacture  f)f  trusses  has  Ijecome  an  important  business  in 
this  country',  and  correspondence  with  all  oi  tlie  larger  firms 


MECHANICAL  TREATMENT.  117 

enables  me  to  state,  that  a  conservative  estimate  of  the  numljer 
made  every  year  would  be  fully  three  quarters  of  a  million. 
Some  of  the  manufacturers  gave  a  much  higher  estimate,  and 
the  one  given  is  that  of  the  most  conservative.  One  maker 
alone  claims  to  manufacture  this  number,  but  he  not  only  has 
an  American  trade,  but  does  an  extensive  export  business. 
Truss  manufacturers,  many  of  whom  have  had  large  personal 
experience,  have  done  what  they  could  to  aid  their  patrons,  the 
retailers,  in  the  art  of  truss-fitting.  For  this  purpose,  some 
instrument  makers  have  found  it  advisable  to  select  an 
employe  who  shall  have  acquired  skill  in  the  fitting-room,  but 
to  the  average  druggist  truss-fitting  is  distasteful,  and  most 
frequently  he  sells  the  truss  after  securing  a  measure  of  his 
customer,  usually  taken  over  the  clothing.  On  the  other  hand, 
physicians,  as  a  rule,  avoid  truss-fitting  because  of  their  total 
lack  of  instruction  during  college  days.  They  have  been  duly 
instructed  regarding  the  alarming  conditions  found  in  cases  of 
strangulated  hernia,  and  the  operation  for  its  relief,  but  ha\-e 
not  been  taught  how  to  protect  their  patient  against  this  danger 
by  the  proper  application  of  a  truss.  They  have  been  especially 
well  drilled  in  how  to  apply  "  Professor  Somebody's  pet  splint," 
but  of  truss-application,  which  they  will  have  ten  opportunities 
to  make  for  every  fracture  they  see,  nothing  has  been  taught 
them.  The  patient  is  therefore  in  the  unfortunate  dilemma, 
between  the  truss  seller  and  the  doctor,  of  having  to  select  and 
usually  to  apply  his  own  truss. 

This  work  of  truss-fitting  is  even  more  foreign  to  the  call- 
ing of  the  druggist  than  would  be  the  prescribing  of  medicines. 
He  has  usually  a  very  good  knowledge  of  materia  medica,  but 
knows  little  anatomy,  pathology,  or  surgery.  The  responsi- 
bility is  therefore  with  the  physician,  and  here  it  must  rest. 
When  he  sees  a  case  of  hernia  he  should  decide  upon  its  needs, 
select  the  truss,  apply  it,  and  give  his  patient  to  understand — as 
long  as  he  wears  a  truss  he  requires  the  doctor's  care,  and  that 
he  should  report  several  times  each  year  for  inspection,  even 
though  everything  seems,  to  him,  in  perfect  condition.     Some 


118  ABDOMINAL  HERNIA. 

maniifactiirers  devote  a  portion  of  their  catalogues  to  instruc- 
tions in  truss-fitting,  but  one  of  them  sums  up  the  whole  subject 
in  the  following  laconic  sentence:  "The  best  way  to  leani 
truss-fitting  is  to  do  it."  This  is  good  advice  to  the  physician, 
but  in  this  work  I  hope  to  give  a  more  serviceable  guide  than 
has  hitherto  been  within  the  reach  of  the  general  practitioner; 
the  surgical  part  of  the  subject  has  been  skillfully  dealt  with 
by  others,  but  the  equally  important  mechanical  part  has  been 
given  only  superficial  attention. 

Trusses  are  remedies  for  the  treatment  of  hernia,  and  from 
the  excellent  variety  made  it  is  usually  possible  to  select  one 
suited  to  the  requirements  of  a  case  in  hand.  He  who  expects 
to  treat  all  types  of  hernia  with  a  single  form  of  truss  is  as  far 
wrong  as  the  doctor  who  is  looking  for  one  drug,  or  a  com- 
bination of  drugs,  that  shall  be  suited  to  the  cure  of  all  his 
patients.  For  this  reason  patented  trusses  are  unreliable,  as  a 
rule ;  in  fact,  I  know  of  no  patented  trusses  worthy  of  extensive 
use. 

A  considerable  variety  of  good  trusses  are  made  by 
reputable  manufacturers,  who  are  very  willing  to  make  any 
variation  that  physicians  may  suggest  in  their  construction. 
The  difference  between  such  trusses  is  largely  in  detail  of 
construction,  the  types  being  essentially  the  same,  and  none  will 
be  mentioned  in  this  work  that  cannot  be  obtained  from  any 
of  the  large  producers.  The  United  States  leads  the  world  in 
production;  in  fact,  it  is  safe  to  say  that  more  good  trusses 
are  made  in  this  country  than  in  all  of  the  rest  of  the  Avorld 
put  together. 

CLASSIFICATION     OF     TRUSSES. 

It  has  been  a  serious  problem  to  present  to  my  reader 
a  large  variety  of  good  appliances,  from  which  he  may  select 
intelligently,  without  transforming  my  work  into  a  truss- 
maker's  catalogue.  It  is  essential,  however,  that  the  reader  be 
shown  what  is  believed  to  be  the  better  types,  as  well  as  some 
of  the  bad  ones,  and  told  wherein  the  latter  are  defective,  so  that 


MECHANICAL  TREATMENT. 

Group  of  Springless  or  Elastic  Truss  Type. 


110 


I.     Ordinary  single  elastic  truss. 


2  .     Elastic  truss  with  special  pad. 


3.     Double  elastic  truss  with  elliptic  spring  on  front  plate. 


4.    Elastic  truss  with  German  pad. 


120  ABDOMINAL  HERNU. 

Group  of  Springless  or  Elastic  Truss  Type  {^Continued). 


5.     One  piece  elastic  truss. 


6.     Elastic  truss  with  hard  rubber  front  plate. 


7.    Moc-Main  ( English)  truss,  leather. 


MECHANICAL   TREATMENT.  121 

he  may  discriminate  against  them.  I  have  endeavored  to  solve 
this  proljlem  hy  grouping  together  those  of  a  certain  type  and 
speaking  of  them  in  a  general  way,  rather  than  individually. 
All  worthy  of  favorable  or  unfavorable  mention  have  been 
placed  in  a  few  groups,  and  the  reader  can  readily  fix  in 
mind  the  principles  involved  in  each.  This  grouping  is  also  in 
a  measure  historical,  for,  as  a  matter  of  fact,  endless  varieties 
have  descended  from  a  few  types.  These  groups  have  been 
placed  in  the  following  historical  order : 

(i)  Springless  type.     Earliest  history   (900  B.C.)   to  date. 

(2)  French^German  type.     1306. 

(3)  Cross-body  type  (English).     Royal  Pat.,  October  27,  1806. 

(4)  Chase  type    (American).     1837. 

(5)  Hood  type    (American).     1847. 

(6)  Unclassified. 

Perhaps  the  remotest  historical  record  of  the  truss  is  con- 
tained in  the  statuette,  a  cut  of  which  is  at  the  beginning  of 
this  chapter.  There  is  little  doubt  that  the  earliest  form 
consisted  of  a  pelvic  belt  with  a  compress  over  the  inguinal 
canal,  held  in  place  by  a  perineal  strap.  From  this  prehistoric 
truss  used  by  many  nations,  civilized  and  uncivilized,  has 
descended  the  group  of  springless  trusses,  a  very  few  of  which 
are  shown.  In  this  country  they  have  been  best  known 
as  the  "  elastic  truss  "  jjecause  of  their  being  made  of  heavy 
elastic  web.  In  England  this  type  is  known  as  the  ]\Ioc- 
Main,  and  consists  of  a  strong  pelvic  belt,  made  of  leather, 
to  which  is  attached  a  good-sized  pad  held  down  by  a  perineal 
strap  (no.  7  of  group).  It  is  believed  to  be  in  many  respects 
better  than  our  elastic  truss.  It  is  more  durable,  and,  being  non- 
elastic,  is  more  reliable  in  the  retention  of  the  hernia.  There  is 
also  upon  the  pad  a  small  spring,  to  which  the  perineal  strap 
buttons,  that  turns  its  lower  end  under,  giving  an.  upward  as 
well  as  a  l)ackward  pressure. 

I  regret  to  state  that,  in  this  country,  more  elastic  trusses 
are  sold  than  any  other  form.     That  this  is  not  because  of  their 


V22 


ABDOMINAL  HERNIA. 


■^^ ^ 


^ ^^ 


—  a 

■>!-  bo 
«5"^ 


"^    bo 


BO 


MECHANICAL  TREATMENT.  123 

greater  value  is  demonstrated  by  the  fact  that  some  manu- 
facturers who  supply  such  a  large  demand  seldom  use  them,  in 
their  own  fitting-rooms,  when  the  truss-selection  is  left  to  their 
best  judgment.  Their  extensive  sale  is  due  largely  to  the  fact 
that  they  require  no  fitting.  Those  suffering  from  hernia  can 
buckle  them  on  without  difficulty.  Furthermore,  they  wear  out 
much  sooner  than  other  forms,  the  wearer  frequently  being 
obliged  to  renew  his  truss  two  or  three  times  a  year  instead  of 
wearing  it  several  years.  Springless  trusses  are,  however,  very 
defective  in  action,  and  their  use  in  many  instances  results  in 
serious  trouble.  Few  people  wear  them  for  any  length  of  time 
without  finding  their  hernise  worse  than  when  they  began. 
This  occurs  because  the  pad  is  drawn  down  against  the  pubic 
bone  by  the  perineal  strap,  leaving  the  upper  part  of  the  canal 
unprotected  and  consequently  occupied  most  of  the  time  by  a 
part  of  the  hernia.  A  hernia  held  at  the  external  ring  only,  is 
poorly  held  and  sure  to  increase.  If  the  pelvis  were  as  round 
as  a  barrel,  the  springless  truss  would  be  more  effective,  but 
as  its  transverse  diameter  exceeds  by  fully  one-third  its  antero- 
posterior diameter,  it  is  thoroughly  unscientific  (fig.  59). 

A  flexible  band  surrounding  the  hips  and  drawn  tightly, 
will  produce  far  more  pressure  over  each  hip  than  over  the 
inguinal  region  where  it  is  needed.  A  band  of  this  character 
will  not  maintain  its  position  upon  the  body  without  the 
perineal  strap,  and  this  is,  for  reasons  which  will  suggest  them- 
selves, an  abomination,  as  well  as  positively  injurious.  The 
importance  of  retaining  hernia  within  the  internal  ring  can- 
not be  too  strongly  emphasized.  In  many  instances  injury 
results  from  placing  the  supporting  pad  over  the  pubic  bone 
and  external  ring,  allowing  thereby  the  upper  part  of  the 
canal  to  be  constantly  occupied  by  a  loop  of  bowel  or  piece 
of  omentum,  and  compressing  the  cord  against  the  bone,  pro- 
ducing atrophy  of  the  testicle  in  some  instances.  Added  to 
this  is  their  lack  of  cleanliness,  which  alone  is  quite  enoug'h 
to  condemn  them  for  general  use.  They  have  one  valuable 
use  and  that  is,  as  a  night  truss.     Ordinarily  this  is  not  needed 


124  ABDOMINAL  HERNIA. 

by  the  adult,  but  if  from  the  enormous  size  of  the  hernia  or  a 
persistent  cough  the  protrusion  takes  place  at  this  time,  these 
springless  trusses  serve  a  good  purpose.  There  is  little  doubt 
that  most  wearers  would  get  a  greater  degree  of  improvement 
by  the  use  of  a  night  truss,  but  the  one  that  is  exactly  suited  for 
the  day  is  entirely  unsuited  for  the  night,  and  the  reverse  holds 
equally  true. 

French,  German,  and  English  Trusses. — In  the  second 
group  is  shown  a  type  of  truss  that  has  been  well  known 
in  this  country,  and  in  most  foreign  countries,  for  many 
years.  There  are  an  endless  number  of  variations  in  the  minor 
details  of  its  construction,  but  the  general  type  remains. 
Doubtless  it  represents  the  first  form  of  metal  spring,  and  it 
had  its  origin  either  in  Italy  or  France,  probably  the  latter. 
The  first  recorded  use  of  metal  for  a  truss  spring  was,  accord- 
ing to  Macready  (A  Treatise  on  Ruptures,  Jonathan  F.  C.  H. 
Macready,  F.  R.  C.  S..  p.  195),  the  iron-band  truss  recom- 
mended by  Gordon  in  1306.  Steel  was  first  used  by  Nicolas 
le  Quin  of  Paris  ("  The  Sign  of  the  Golden  Truss  ")  in  1628. 
It  is  possible  to  present  onlv  a  few  of  the  numerous  descendants 
of  this  type.  In  this  country  they  have  been  known  to  manu- 
facturers as  the  French  (nos.  6,  7,  and  8  of  group)  or  German 
(nos.  3,  4,  and  5  of  group)  truss,  the  only  distinguishing 
feature  between  them  being  that  the  former  are  made  lighter, 
and  usually  bear  some  decorations  in  tlie  form  of  fancy  stitch- 
ing or  embossed  flowers  upon  the  leather  forming  the  outer 
surface  of  the  pad. 

This  form  of  truss  as  made  in  England  (nos.  i  and  2  of 
group)  is  superior  in  two  important  particulars  to  those  made 
here,  and  whether  their  origin  was  the  same  is  not  known.  In 
the  French-German  truss  the  spring  passes  around  the  back  to 
a  point  three  or  four  inches  beyond  the  spine,  terminating  over 
the  gluteal  muscles.  In  the  English  form  this  spring  continues 
far  enough  around  to  clasp  the  opposite  hip,  thereby  holding 
itself  securely  in  place.  It  also  has  the  retaining  pad  placed  in 
a   line   almost   parallel    with    the    spring    instead    of   arching 


MECHANICAL  TREATMENT. 


12; 


Group  of  Trussp:s,  Frknch,  German,  and  Encilish  Tvpks. 


I.     Single  English  type. 


2.     Double  English  type. 


3.    Single  German  type. 


126  ABDOMINAL  HERNIA. 

Group  of  Trusses,  French,  German,  and  English  Types  {Continued). 


4.     German  type  (so-called  "  scrotal-hernia  truss'"). 


5.     Double  German  truss. 


6.     French  truss. 


Adjustable  French  truss. 


8.     Hard-rubber  or  celluloid   Frencl'  truss. 


MECHANICAL  TREATMENT. 


127 


abruptly  down  over  the  pubic  bone  as  in  the  French-German 
truss.  These  are  two  serious  defects  in  most  oi  the  trusses 
made  in  the  United  States  and  Germany.  Fortunately  some 
of  the  larger  manufacturers  are  recognizing  this  defect  and 
endeavoring  to  correct  it.  The  centre  of  the  truss  pad  should 
be  very  nearly  on  a  line  with  the  centre  of  the  spring,  in  order 
to  have  it  effective  and  comfortable.     When  the  pad  is  thrown 

Fig.  6o. 


Typical  illustration  of  bad  truss  fitting  with  a  French-German  truss,  frequently 
seen.  Note  that  the  pad  acts  as  a  compress  directly  over  the  pubic  bone,  and  that  the  hernia 
is  in  the  canal  above. 


down  SO  low  that  its  lower  edge  rests  upon  the  pubic  bone  it 
ceases  to  be  a  reliable  support,  acts  as  a  compress  over  the  bone, 
and  may  for  a  time  keep  the  hernia  out  of  the  scrotum,  but 
the  canal  is  gradually  being  dilated  to  such  an  extent  that  the 
hernia  eventuallv  becomes  almost,  if  not  quite,  uncontrollable. 
The  accompanving  illustrations  (figs.  60,  61,  and  62)  show 
this  serious  defect  in  truss-making  and  truss-wearing.  The 
first  pictures  the  case  of  a  young  man  who,  under  the  use  of  this 


128 


ABDOMINAL  HERNIA. 


type,  had  gradually  grown  worse  until  it  was  almost  impos- 
sible to  retain  his  hernia,  it  is  not  uncommon  to  see  these 
trusses  worn  in  this  way.  The  second  photograph  shows  him 
with  a  Hood  truss  holding  his  hernia  in  proper  position.  As 
he  was  weak  upon  the  left  side,  a  thin  pad  for  moderate  support 
was  placed  over  that  region. 

Perhaps  the  worst  feature  of  this  form  of  truss,  as  now 
made,  is  in  the  fact  that  even  if  the  pad  is  properly  placed  over 

Fig.  6i. 


Same  case  as  Fig.  60,  with  properly  adjusted  De  (Jarnio-Hood  truss  retaining-  hernia  within 
abdomen  and  with  thin  pad  for  support  of  opposite  side. 


the  inguinal  canal,  it  will  in  a  short  time  drop  down  over  the 
pubic  bone.  The  reason  for  this  is  that  the  spring  naturally 
seeks  the  spot  around  the  hips  where  it  is  least  inlluenced  by 
muscular  action.  This  neutral  point  is  midway  between  the 
crest  of  the  ilium  and  tlie  trochanter  major  (fig.  63),  above 
the  active  muscles  of  the  thigh  and  lielow  those  of  the  abdomen. 
In  this  position  the  front  end  of  the  spring  terminates  over 


MECHANICAL  TREATMENT. 


129 


the  middle  of  the  canal.  If  the  retaining  pad  is  two  inches 
below  the  spring,  it  will  be  seen  at  once  that  it  must  rest  upon 
the  pubic  bone  when  the  spring  rests  in  its  normal  position. 
This  criticism  applies,  with  equal  force  to  all  of  that  vast  variety 
of  trusses  of  the  type  shown  in  the  group  under  consideration 
and  by  the  Chase  type,  to  be  "spoken  of  shortly.     The  English 


Usual  maimer  of  wearing  the  so-called  German  style  of  truss.     The  hernia;  on  both  sides  are 
protruding  into  the  scrotum.     The  canals  are  entirely  unprotected. 


type  of  this  group  is  very  good,  and  the  farther  away  from  this 
form  the  more  imperfect  is  the  truss  of  this  pattern.  While 
trusses  of  this  group  have  an  enormous  sale  few  expert  truss- 
fitters  use  the^n ;  the  German  instrument  and  truss  makers, 
however,  use  them  almost  to  the  exclusion  of  all  others. 

Cross-Body  Type. — Towards  the  close  of  the  eighteenth 
century,  Salmon  &  Ody,  an  English  firm  still  in  existence,  made 
9 


130 


ABDOMINAL  HERNIA. 


an  important  change  in  the  form  of  truss  springs,  establishing 
one  of  the  most  valuable  types  of  truss  that  we  now  have 
for  the  treatment  of  single  inguinal  and  femoral  hernia,  known 
as  the  cross-body  truss  (no.  i  of  group).  The  spring,  in- 
stead of  surrounding  the  hip  on  the  side  of  the  hernia,  passes 
from  the  canal  directly  across  the  lower  abdomen  and  around 

Fig.  63. 


Position  in  which  spring  should  rest  about  hip.  Midway  between  crest  of  ilium  and  tro- 
chanter major,  its  end  in  front  over  internal  ring.  If  it  comes  across  abdomen  it  should  termi- 
nate at  the  same  point. 

the  hip  of  the  opposite  side.  As  originally  made  this  truss  had 
a  convex  pad  over  the  inguinal  region,  held  to  the  spring  by  a 
ball-and-socket  attachment.  The  spring  after  passing  across 
the  abdomen  and  around  the  hip  opposite  the  hernia,  terminated 
over  the  spine,  where  there  was  another  circular  pad  held  by  the 
same  method  of  attachment. 

lliis  truss  was  later  modified,  in  this  counti'y,  by  putting 


MECHANICAL  TREATMENT.  131 


Group  of  Trusses  of  the  Cross-Body  Type. 


I.     Cross-body  truss,  leather  cover,  ball-and-socket  pad. 


2.     Hard-rubber  cross-body  truss. 


3.     Hard-rubber,  cross-body  truss,  small  back  pad.     Continuous-spring 


4.     Hard-rubber  "  radical-cure  truss." 


132  ABDOMINAL  HERNL\. 

Group  of  Trusses  of  the  Cross-body  Type  {Continued). 


5.    Radical-cure  truss.    Continuous-spring  cross-body 


6.    Leather  covered  continuous-spring  cross-body  truss. 


7.    Radical-cure  truss,  large  leather  covered  back  pad. 


MECHANICAL  TREATMENT. 

Group  ok  Trusses  of  the  Chase  Type. 


133 


I.    Chase  truss. 


2.     Foster  ratchet  modified  Chase  truss. 


3.     Adjustable  pad  Chase  truss. 


4.    Adjustable  ball-and-socket,  with  set  screw. 


134  ABDOMINAL  HERNIA. 

Group  of  Trusses  of  the  Chase  Type  {Continued). 


5.     Modified  set  screw  Chase  truss. 


6.     Modified  hard-rubber  Chase  truss. 


7.    Curved  neck,  ratchet  pad. 


Adjustable  pad  and  set  screw. 


MECHANICAL  TREATMENT.  135 

on  an  elongated  back  pad  (nos.  i,  2,  and  4)  that  should  press 
on  either  side  of  the  spine,  its  centre  being  arched ;  and  by 
making  the  spring  longer  (nos.  3,  5,  and  6)  so  that  it  would 
terminate  over  the  gluteal  region,  directly  back  of  the  hernia, 
either  in  a  circular  pad  or  continuous  with  the  strap  that  com- 
pletes the  circumference.  The  special  advantages  of  this 
spring  are — that  it  surrounds  fully  three-fourths  of  the  body 
and,  when  properly  fitted  will  retain  its  position,  even  though 
no  strap  is  used ;  it  furnishes  a  longer,  and  therefore  a  more 
elastic,  spring.  The  direction  of  the  pressure  is  from  the  front 
pad  to  the  centre  of  the  back,  and  as  it  crosses  the  back  at  a 
slight  elevation  over  the  front,  it  has  a  slight  upward  pressure. 
It  is  convenient  to  the  dealer  because  it  can  be  quickly  converted 
from  a  right-  to  a  left-side  truss.  There  are  many  modifica- 
tions as  to  the  form  of  retaining  pad  and  its  method  of  attach- 
ment to  the  spring,  but,  while  convenient,  they  are  not  essential. 

In  this  form,  with  such  modifications  as  can  be  made  to 
suit  individual  peculiarities,  we  have  one  of  the  most  valuable 
appliances  for  the  treatment  of  hernia  that  has  ever  been 
devised. 

Chase  Type. — This  form  began  with  the  truss  bearing 
the  name  of  its  inventor,  Dr.  Heber  Chase,  1837.  It  was 
issued  during  the  war  of  the  Rebellion  (1861-5)  to  soldiers 
who  developed  hernia  in  the  service.  It  consisted  of  a  spring 
of  the  French  type  to  which  was  attached  in  front  a  soft, 
malleable  iron  neck,  curved  downwards,  holding  a  polished 
cedar  pad.  The  pad  was  held  by  screws,  passing  through  a 
slot  in  the  iron  neck,  so  that  it  could  be  raised  or  low^ered  and 
the  neck  easily  bent  into  any  desired  position.  The  truss  was 
considered  quite  an  improvement  on  its  prototype  which 
undoubtedly  was  the  French  truss.  It  has  many  descendants,  a 
few  of  which  are  shown  in  their  group. 

To  a  lesser  degree  they  are  all  open  to  the  objections  that 
have  been  offered  to  the  French  type.  The  pad-centre  being 
considerably  below  the  spring-centre  is  an  objection  already 
mentioned.     Also,  the  springs  like  all  those  that  go  on  from  the 


136  ABDOMINAL  HERNIA. 

same  side  as  the  rupture,  are  dependent  upon  the  strap  for 
retention  of  position,  and  when  this  stretches,  or  is  improperly 
adjusted,  they  are  very  hable  to  shift  their  position  and  allow 
the  hernia  to  protrude.  For  perfect  fitting,  comfort,  and 
security,  they  do  not  compare  favorably  with  the  cross-body  or 
Hood  type  of  truss. 

Hood  Type. — This  is  apparently  an  original  type,  purely 
American,  the  invention  of  Dr.  J.  W.  Hood  of  Kentucky. 
In  its  existence  of  nearly  seventy  years,  this  truss  has  passed 
through  many  hands  and  has  been  the  subject  of  many  im- 
provements, but  its  general  type  remains.  Its  spring  is  solid 
in  front,  surrounding  both  hips,  and  terminates  within 
about  two  inches  of  the  spine  on  either  side.  Usually  it  has 
circular  pads  attached  to  the  spring  ends  in  the  back  upon 
which  the  counter  pressure  is  taken,  but  some  makers  put  on 
instead  a  flat,  oblong  disk  which  broadens  the  spring  at  this 
point  and  distributes  the  pressure  over  a  greater  surface.  The 
retention  pads  used  in  front  are  of  various  shapes  and  designs, 
and  may  be  selected  to  suit  individual  requirements.  The 
original  Hood  pad  is,  however,  for  general  use,  an  excellent 
form.  It  is  thick  at  its  lower  edge,  thin  at  the  top,  and  in 
action  presents  a  moderately  convex  surface  over  the  inguinal 
canal.  The  pubic  portion  of  the  Hood  spring  has,  on  either 
side,  a  slot  which  runs  parallel  with,  and  is  directly  over,  the 
inguinal  canal.  Transversly  to  this  slot  is  another  in  the  pad, 
and  between  the  two  there  is  quite  a  wide  range  of  movement 
for  accurate  adjustment.  When  the  adjustment  is  complete 
the  pad  is  solidly  fixed  to  the  spring  by  set  screws,  which 
prevents  motion  between  them  while  in  use. 

The  action  of  this  truss  is  peculiar  in  that  it  does  not 
depend  wholly  upon  compression  or  spring  action.  It  has.  in 
fact,  been  extensively  and  very  successfully  used  in  a  metal  that 
has  scarcely  any  spring  action.  It  acts  as  a  resisting  frame 
about  the  pelvis  with  the  pad  making  firm  pressure  over  the 
inguinal  canal  when  the  wearer  is  in  an  upright  position. 
Should  he  cough  or  strain,  the  abdominal  wall  is  thrown  for- 


MECHANICAL  TREATMENT. 

Group  of  Trusses  of  Hood  Type. 


137 


138  ABDOMINAL  HERNIA. 

Group  of  Trusses  of  Hood  Type  [Cojttinued). 


MECHANICAL  TREATMENT.  139 

Groui>  of  Trusses  of  Hood  Tvi'K  [Continued). 


T2. 


140  ABDOMINAL  HERNIA. 

ward,  but  firmly  met  and  restrained  by  the  pad  fastened  to  the 
pelvic  frame.  If,  however,  he  should  lie  down,  the  frame 
would  not  follow  to  any  extent  the  receding  surface  of  the 
abdominal  wall.  Many  truss  makers  have  not  fully  compre- 
hended this   action  of  the  Hood  truss   and  have  made  the 

Fig.  64. 


De  Garmo-Hood  truss    applied.     Right   complete   inguinal  hernia.     Left   incipient  hernia 
retained   by   thin   "dummy  '  jiad. 

Springs  too  heavy  and  with  too  much  action,  this  error  being 
fostered  by  the  necessity  of  strong  spring  action  in  other  forms 
of  truss.  The  fact  that  in  this  truss  a  larger  amount  of  com- 
pression can  be  dispensed  with,  makes  it  a  much  easier  form 
for  the  patient  to  wear.  When  completely  at  rest,  the  wearer 
is  in  a  measure  relieved  of  pressure,  which  is  a  great  comfort, 
quite  in  contrast  with  the  tireless  and  never  ceasing  pressure 


MECHANICAL  TREATMENT. 


141 


from  a  spring,  the  ends  of  which  are  endeavoring  to  come 
together. 

The  Hood  spring  should  surround  the  pelvis  very  nearly 
in  a  straight  line,  and  some  manufacturers  have  ruined  it 
by  arching  the  sides  too  high.  As  soon  as  this  is  done  it 
loses  its  pelvic-frame  action,  the  pads  drop  down  over  the 
pubic  bone,  and  the  truss  then  has  many  of  the  objection- 
able  features   of  the   trusses   which   have   the   pad   set  on   a 

Fig.  65. 


De  Garmo-Hood  truss  applied.      Back  view. 

descending  arm.  The  shapes  which  are  best  for  general  use 
are  shown  in  Nos.  6,  7,  and  9  of  the  Hood  type  group.  The 
Hood  spring  also  has  the  advantage  of  carrying  one  or  two 
pads,  but  it  is  always  best  with  two.  The  one  over  the  side  not 
ruptured  may  be  very  thin  and  is  called  in  the  trade,  a 
"dummy"  (figs.  64  and  65). 

A  person  with  one  hernia  is  quite  liable  to  develop  another 
on  the  other  side,  which  is  more  likely  to  happen  when  a  single 
truss  is  worn  than  when  none  is  used,   for  the  reason  that 


142  ABDOMINAL  HERNIA. 

the  pressure  against  one  side  of  the  abdomen  throws  the 
intra-abdominal  pressure  towards  the  other  side.  Again, 
where  double  hernia  exists,  this  solid-front  spring  is  desirable 
because  there  can  be  no  change  in  the  relative  position  of  the 
pads,  by  the  stretching  of  a  strap  as  in  other  forms  of  double 
truss,  or  by  error  of  adjustment  by  the  wearer.  Increased 
weight  and  consequent  change  of  size,  is  also  better  provided 
for  by  the  adjustment  of  the  strap  in  the  back  than  in  front.  A 
person  may  gain  or  lose  several  inches  in  size  without  any  rela- 
tive change  in  the  position  of  the  two  inguinal  canals.  When 
the  wearer  becomes  tired  and  wishes  to  relax  the  constriction 
of  a  truss,  it  can  be  done  if  fastened  in  the  back,  without 
disturbing  its  position  in  front ;  on  the  contrary,  if  the  pads  are 
held  in  position  by  a  strap  in  front,  the  moment  this  is  loosened 
they  are  out  of  adjustment  and  the  wearer  is  liable  to  accident. 

The  truss  of  this  type  that  I  have  used  for  many*  years, 
more  than  any  other,  is  shown  in  no.  7  of  group,  or  fig.  64 
and  65,  applied.  It  differs  from  the  others  principally  in  its 
lightness,  simplicity  of  construction,  and  in  the  fact  that  the 
spring  is  made  of  hard-rolled  German  silver  instead  of  steel. 
It  is  covered  by  hard  rubber  and  the  pads  are  attached  by  simple 
clasps  that  allow  of  adjustment. 

There  are  few  expert  truss  fitters  in  this  country  who 
have  not  used  extensively  the  Hood  type  of  truss,  while  some 
have  used  it  almost  to  the  exclusion  of  all  -other  forms.  It  is 
easier  to  fit  than  almost  any  other,  and  certainly  easier  to  wear. 
The  special  advantages  of  the  Hood  truss  are  believed  to  be  : 

(i)  It  passes  around  the  pelvis  at  the  most  immovable  part. 

(2)  Surrounding  both  hips  gives  it  stability. 

(3)  It  retains  with  relatively  less  pressure. 

(4)  It  protects  one  or  both  canals. 

(5)  Counter   pressure   is   on   the   gluteal    region    where   best 

tolerated. 

It  has,  however,  the  disadvantage  of  being  somewhat 
more  expensive  to  manufacture  than  other  forms,  and  for  this 


MECHANICAL  TREATMENT. 


143 


Unclassified  Group. 


I.    Wire-Spring  Truss. 


2.    Spring  and  elastic  web  combined 


3.    Spring  and  elastic  web  combined. 


144 


ABDOMINAL  HERNIA. 

Double  Truss  Group. 


I.    Double  ball-and-socket  truss. 


2.     Double  hard-rubber  truss. 


3.     Modified  Chase  Truss. 


MECHANICAL  TREATMENT 

DouiiLE  Truss  Group  {Cojiiinucd). 


145 


4.    Modified  radical-cure  truss. 


5      Radical-cure  truss. 


6.     Adjustable  set-screw  truss. 


146 


ABDOMINAL  HERNIA. 

Double  Truss  Group  [Coniimced). 


7.    Elastic  web  and  spring  truss. 


8.     Adjustable  French  truss. 


9.     Double  elastic  truss. 


10.     Double  German  truss. 


MECHANICAL  TREATMENT.  147 

reason  alone,  many  truss  sellers  have  declined  to  carry  them 
in  stock.  The  physician  should  impress  upon  liis  patient  the 
truth,  that  to  the  ruptured  man  a  good  truss,  well  fitted,  is 
more  important  to  him  than  his  clothes.  Undue  economy  in 
this  connection  is  poor  policy. 

Unclassified  Group. — There  is  also  a  group  of  trusses 
that  cannot  be  classified  with  any  of  those  already  mentioned. 
It  contains  one  upon  which  I  have  never  looked  w'ith  much  favor 
though  I  have  known  good  truss  fitters  (no.  i)  unbiased  by 
personal  interest,  who  claim  to  have  found  it  satisfactory.  Large 
numbers  have  been  sold  to  dealers  throughout  the  country,  and 
for  that  reason  it  seems  best  to  mention  it  here.  It  has  the  ap- 
pearance of  an  original  type  of  truss,  and  I  believe  the  makers 
considered  it  such,  but  as  a  matter  of  fact  Dr.  Tod  of  Lon- 
don, England,  patented  (about  1858)  a  truss  to  which  this  is 
exactly  similar  except  in  details  of  construction,  his  being 
made  of  a  steel  spring  occupying  exactly  the  same  position  as 
this,  held  in  place  by  a  similar  band,  while  this  is  made  of  spring 
brass,  or  other  wire,  so  shaped  that  one  piece  forms  not  only 
the  spring,  but  the  frames  for  both  the  front  and  back  pads. 
The  advantages  of  this  truss  are  in  its  extreme  lightness  and 
small  cost  of  construction.  Its  disadvantages,  as  they  present 
themselves  to  me,  are  its  great  liability  to  become  displaced,  lack 
of  durability  and  general  inefficiency.  Its  retention  in  place  is 
absolutely  dependent  upon  the  web  band  which  surrounds  two- 
thirds  of  the  hip.  Furthermore,  the  lengih  of  the  spring,  from 
the  crest  of  the  ilium  to  the  hernial  pad  in  front,  is  such,  that  in 
bending  forward  the  pad  is  forced  down  over  the  pubic  bone. 
Wearers  have  complained  to  me  in  reference  to  this  as  a 
great  inconvenience,  and  it  is  certain  that  any  truss  pad  that 
is  so  liable  to  displacement,  must  be  looked  upon  as  very 
dangerous. 

Nos.  2  and  3  of  this  group  represent  a  combination  of  a 
short  steel  spring  with  an  elastic  band.  It  is  a  modification  of, 
and  I  should  think  something  of  an  improvement  upon,  the 
elastic  truss. 


148  ABDOMINAL  HERNIA. 

Double  Truss  Group. — This  group  merely  presents  the 
same  type  of  trusses  already  illustrated,  as  arranged  for  double 
instead  of  single  hernia. 

Retaining  Pads. — Pads  for  the  retention  of  the  hernia  are 
made  of  many  shapes,  and  are  usually  interchangeable  so  that 
the  fitter  can  make  almost  any  combination  of  spring  and  pad 
that  he  may  desire  (fig.  66).  In  ordering  pads  it  is  only 
necessary  to  state  the  form  of  spring  they  are  intended  to  be 
used  on,  and  suitable  screws  for  attachment  will  be  placed  on 
them.  For  general  use  the  best  form  is  a  moderately  convex, 
oblong  pad  such  as  shown  in  nos.  3  and  7  of  the  pads  grouped 
on  the  accompanying  plate.  These  oval  pads  are  made  in 
several  sizes,  as  shown  in  the  diagram  of  sizes  (fig.  67)  ; 
using  an  unnecessarily  large  pad  is  a  mistake  most  frequently 
made.  This  is  especially  true  in  the  treatment  of  large  sized 
hernise.  The  larger  the  pad,  the  stronger  the  spring  pressure 
must  be.  With  the  smaller  pad  the  pressure  is  concentrated 
immediately  upon  the  spot,  while  if  that  same  pressure  is  dis- 
tributed over  a  large  area,  it  ceases  to  be  effective.  A  thin, 
flat  pad  answers  well  for  a  thin  person,  but  upon  a  fat  patient,  a 
deeper  pad,  such  as  No.  8  of  pad  group,  must  be  selected. 

The  pads  are  made  either  of  soft  material,  felt,  hair,  or  of 
hard  material,  such  as  wood,  hard  rubber,  or  celluloid.  A  soft 
pad  that  has  proven  useful  is  known  as  the  water  pad. 
This  is  made  in  every  conceivable  size  and  shape,  and  consists 
of  a  rubber  bag  filled  with  water  or  glycerine,  sealed.  Over 
this  is  a  layer  of  felt  and  then  a  covering  of  silk,  kid,  or 
chamois.  In  some  special  cases  this  is  a  valuable  pad,  but  its 
lack  of  durability  is  a  serious  defect.  If  the  wearer  is  cautioned 
about  its  tendency  to  flatten  out  and  leave  him  unprotected,  it 
may  save  serious  trouble.  This  change  is  so  gradual  that  unless 
attention  is  drawn  to  it,  it  may  not  be  noticed.  For  general 
use  there  is  no  pad  made  that  equals  in  durability,  cleanliness, 
and  reliability,  those  made  of  hard  rubber  or  celluloid.  The 
skin  maintains  a  much  healthier  condition  under  the  pressure  of 
a  highly  ])ohshed,  impervious  surface,  than  any  soft  material 


MECIIANICAl.  TREATMENT 

Fig.  66. 


149 


TOP 


Group  of  Variously  Shaped  Pads 


Fig.  67. 


150 


A  Standard  of  Sizes  for  Truss  Pads.  {Horn.) 


MECHANICAL  TREATMENT.  151 

that  is  constantly  accumulating"  tlie  cxcreti(jns  of  the  skin. 
Ordinarily  tlic  hard  pad  is  ccjualiy  comfortable  to  wear,  if 
i:)laced  in  proper  position,  and  does  not  impinge  upon  the 
bone  or  other  hard  parts.  The  tissues  back  of  the  pad  are  soft 
and  flexible,  conforming  readily  to  the  shape  of  the  pad,  thus 
closing  the  upper  part  of  the  canal. 

Truss  Coverings. — The  material  with  which  a  truss  spring 
is  covered  has  little  to  do  with  its  efficiency,  but  may  make 
much  difference  in  comfort,  cleanliness,  and  durability.  Clean- 
liness of  both  person  and  appliance  is  the  first  essential  of 
comfortable  truss  wearing,  and  it  is  for  this  reason  that  hard 
rubber  and  celluloid  make  the  most  desirable  materials  with 
which  to  cover  truss  springs  and  make  the  pads.  In  using 
these  materials  retaining  pads  can  be  made  hollow,  and  there- 
fore very  light. 

The  use  of  hard  rubber  in  truss-making  was  the  invention 
of  Dr.  J.  W.  Riggs  of  New  York  City,  about  1865,  and  was 
one  of  the  most  valuable  contributions  ever  made  in  the  interest 
of  the  truss  wearer.  The  names  of  Riggs,  Chase,  and  Hood, 
all  reputable  physicians,  should  long  be  remembered  in  connec- 
tion with  the  great  advance  of  this  country  over  other  nations 
in  truss  construction.  Manufacturers  are  to  be  congratulated 
upon  the  excellence  of  their  products,  but  we  must  still  claim 
for  the  medical  man  the  honor  of  having  made  the  most  valu- 
able suggestions.  In  individual  cases,  especially  in  aged,  thin, 
and  sensitive  people,  it  may  be  very  advisable  to  have  trusses 
constructed  of  the  softest  possible  material,  but  for  the  average 
wearer  there  is  nothing  equal  to  the  hard  rubber  or  celluloid, 
which  insures  cleanliness,  as  they  will  not  absorb  the  excretions 
of  the  skin.  They  can  be  washed  in  water,  or  boiled  if  worn 
during  contagious  disease.  Physicians  frcc[ucntly  make  -the 
mistake  of  speaking  of  the  "  Hard-Rubber  Truss  "  or  "  Cellu- 
loid Truss  "  as  though  they  were  some  definite  type  of  truss. 
This  is  an  error,  as  these  names  merely  refer  to  the  materials 
used  in  construction  and  are  applied  by  makers  to  every  known 
type  of  truss. 


CHAPTER  VIII. 

TRUSS-FITTING. 

The  fitting  of  trusses  is  an  art  that  is  difficult  for  a  person 
to  acquire  who  has  no  mechanical  tastes  or  ability.  Such  a 
man  would  seldom  become  an  expert,  but  if  persistent,  would, 
with  practice,  do  the  work  fairly  well.  It  requires  in  addition 
to  some  mechanical  skill,  patience  unlimited,  persistence  until 
the  ideal  is  attained,  and  tact  in  managing  the  patient,  especially 
if  he  is  an  old  truss  wearer  and  has  "ideas"  regarding  his 
needs.  Unfortunately  every  beginner  has  had  to  acquire  skill 
by  personal  experience,  and  when  he  has  obtained  this  it  has 
been  considered  shrewd  business  policy,  by  the  non-professional 
expert,  to  impart  as  little  of  his  knowledge  as  possible  to  others. 
There  is  no  valuable  guide  to  truss-fitting  and  largely  because 
those  who  have  written  on  hernia  have  had  surgical  experience 
only,  while  those  who  have  had  experience  in  truss-fitting  have 
"  bottled  it  up,"  fearing  that  their  rivals  might  be  benefited 
by  it. 

Truss-fitting  consists  of  obtaining  the  measure  and  shape 
of  the  patient,  selecting  the  truss  suited  to  the  case,  shaping  of 
the  spring,  and  its  application  to  the  patient.  The  patient 
should  also  be  instructed  in  the  reduction  of  his  own  hernia,  in 
the  removal  and  readjustment  of  the  truss,  in  the  necessity  of 
care  and  cleanliness  of  the  skin,  and  last,  but  not  least,  in  the 
importance  of  returning  for  refitting  and  inspection. 

Taking  Measure  and  Shape. —  Every  person  is  differently 
formed,  even  though  the  circumference  be  exactly  the  same,  so 
that  it  is  equally  as  important  to  consider  the  shape  as  the  meas- 
ure. Manufacturers  can  only  follow  one  general  shape  for  a 
certain  size,  therefore,  if  a  patient  buys  a  truss  from  stock  that 
fits  him,  it  is  because  he  happens  to  fit  the  truss.  Practically 
each  truss  should  be  shaped  to  the  form  of  the  person  that  is  to 
wear  it,  and  recognizing  this  fact,  truss  makers  temper  their 

152 


TRUSS-FITTING. 


153 


springs  so  that  they  can,  with  care,  be  bent  to  the  required  form 


with  little  risk  of  breaking-. 


for  inguinal  hernia 


The  measure  for  a  truss  (fig.  68) 
should  be  the  entire  circumference  of  the  pelvis,  about  level  with 
the  internal  ring,  passing  midway  between  the  crest  of  the  ilium 
and  the  trochanter  major,  and  with  the  tape  a  little  higher  in 
the  back  than  in  front,  corresponding  with  the  pelvic  obliquity. 


Fig.  68. 


Showing;  location  in  which  measure  should  be  made  for  inguinal  truss.    Tape  should  pass 
midway  between  trochanter  major  and  crest  of  ilium.     (Mactcady.) 

This  measure  should  be  recorded  in  number  of  inches,  and  fol- 
lows the  line  properly  covered  by  the  truss  spring  as  shown 
in  fig.  63.  It  is  also  well  to  record  the  measure  from  one 
inguinal  canal  to  the  other  in  double  hernia  in  order  to  locate 
the  pads  at  a  proper  distance  apart,  remembering  that  in  direct 
hernia  the  pads  must  be  nearer  together  than  in  the  oblique 
form. 


154  ABDOMINAL  HERNL\. 

Diagram. — Placing  a  diagram,  on  paper,  of  the  patient's 
pelvis  will  materially  aid  even  an  expert  fitter,  and  it  puts  truss- 
iitting   within   the   possibilities    of   the    inexperienced.      The 

Fig.  69. 


Showing  methfifl  of  taking  diagram  wilh  lead  tape. 

"  Lead-Tape  Method  "  suggested  by  the  author  many  years 
ago,  has  proven  a  very  easy  and  valuable  way  of  doing  this, 
but  has  not  been  as  extensively  known  as  it  should  have  been. 
This  diagram  is  obtained  by  the  use  of  a  strip  of  sheet  lead,  half 


TRUSS-FITTING. 


155 


an  inch  wide,  one-sixteenth  of  an  inch  thick,  and  for  use  on 
adults,  about  twenty  inches  long.  It  can  be  cut  from  the  sheet 
by  any  plumber.     The  end  of  this  lead  tape  is  placed  over 


Fio.  70. 


Showing  method  of  taking  diagram  ;  second  position. 

the  hernia  (fig.  69).  extending  from  this  point  across  the 
front  of  the  abdomen  and  around  the  hip  on  the  opposite 
side,  thence  across  the  back  (fig.  70).  The  lead  is  gently 
pressed  to  the  form  of  the  body,  carefully  removed  and  placed 


156  ABDOMINAL  HERNIA. 

edgewise  upon  a  sheet  of  paper,  or  case  book,  of  suitable  size. 
A  tracing  is  now  made  of  its  inner  surface  with  a  lead  pencil. 
This  will  represent  about  two-thirds  of  the  circumference  of  the 
pelvis  and  when  transferred  to  paper  the  diagram  may  be  com- 
pleted by  turning  the  lead  over  and  completing  the  tracing,  or 


Fig 


Diagrams  of  two  persons  of  32-inch  measure. 

if  preferred  by  repeating  the  process  for  the  other  side.  This 
diagram  gives  the  shape  of  a  section  of  the  hips  taken  on  a 
line  covered  by  the  truss  spring. 

The  shaping  of  a  truss  spring  by  this  diagram  is  much 
easier  than  shaping  it  to  the  patient's  body.  Time  is  saved  to 
the  fitter,  and  the  embarrassment  to  both  the  patient  and  the 
physician  of  repeated  trials  upon  the  body  is  saved.  Usually 
if  the  spring  is  carefully  shaped  to  the  diagram,  very  few,  if 
any.  alterations  will  be  required  when  it  is  put  upon  the  person 


TRUSS-FITTING. 


157 


of  the  wearer.  This  method  so  far  simphfies  truss-fitting  as  to 
l)lace  it  within  the  reach  of  every  practitioner  who  is  wiUing  to 
devote  the  time  necessary.  The  patient  should  be,  and  usually 
is,  willing  to  pay  for  this  time  in  order  to  be  relieved  of  a  very 
dangerous  condition.  The  two  diagrams  show-n  (figs.  71,  72) 
are  reproduced  from  those  of  two  taken  from  my  case  book  of 

Fig.  72. 


Diagrams  of  two  persons  whose  circumference  is  identical. 

two  persons  of  exactly  the  same  measure,  and  illustrate  at  once 
how  impossible  it  would  be  for  one  to  wear  with  comfort  a 
spring  shaped  for  the  other. 

Shaping. — In  truss-fitting  one  should  have  a  pair  of  strong 
pliers,  a  screw-driver,  and  a  pair  of  good  hands,  the  latter 
being  the  most  important  part  of  the  outfit,  as  nearly  all  of  the 
actual  bending  of  the  spring  should  be  done  by  them.  The 
bending  into  the  required  shape  of  a  tempered  spring  must  be 
done  carefully  and  net  by  a  sudden,  jerky  force.     Grasp  the 


158  ABDOMINAL  HERNLV. 

spring  firmly  in  the  hands  as  shown  in  no.  3,  fig.  73,  and  by  a 
steady,  firm  pressure  gradually  bend  it  to  the  point  required. 
In  shaping  by  the  diagram,  begin  at  the  point  over  the 
hernia  and  shape  first  across  the  front  of  the  abdomen,  if  a 
cross-body  truss,  and  then  around  the  hip  and  across  the  back. 
If  the  spring  crosses  the  back  it  must  not  be  allowed  to  press 
upon  the  spine,  but  the  pressure  should  be  taken  up  by  the 
heavy  side  muscles.  If  the  lower  edge  of  the  spring  needs  twist- 
ing farther  in  or  farther  out  to  change  the  bearing  of  the  pad 
or  improve  the  fitting  of  the  truss,  this  should  be  done  by  the 
pliers.  It  must  be  remembered  in  fitting  a  spring  to  the 
diagram,  that  allowance  must  be  made  for  pressure.  The 
spring  must  be  forcibly  held  out  to  the  shape  of  the  diagram. 

All  springs  covered  with  hard  rubber  must  be  thoroughly 
warmed  before  attempting  to  bend  them,  otherwise  the  rubber 
covering  will  crack,  damaging  seriously  the  durability  of  the 
truss.  The  warming  is  done  by  passing  the  spring  rapidly 
through  a  gas  flame  (no.  i,  fig.  73),  or  through  the  flame  of 
an  ordinary  spirit  lamp.  The  latter  method  is  the  best,  as  the 
gas  flame  smokes  it  and  unless  constantly  wiped  will  soil 
the  hands  or  patient's  body.  The  skill  necessary  for  this 
warming  process  is  quickly  acquired,  and  all  that  is  necessary  to 
prevent  burning,  is  to  keep  the  spring  constantly  moving.  An 
equally  good  way,  when  convenient,  and  one  free  from  danger 
of  burning,  is  to  dip  the  spring  in  boiling  water  for  about  one 
minute.  Celluloid  springs  do  not  need  warming  before  bend- 
ing, except  to  see  that  they  are  not  extremely  cold.  They  must 
not,  under  any  circumstances,  be  placed  in  a  flame.  They  are 
readily  distinguished  from  hard  rubber,  which  is  always  black, 
by  their  being  pink  or  white.  Ordinarily  this  material  is  suf- 
ficiently flexible  to  stand  any  necessary  shaping.  It  is  only 
when  the  springs  have  been  kept  long  in  stock  that  they  become 
somewhat  brittle,  and  then  the  pouring  upon  them  of  boiling 
water  will  prevent  cracking. 

Every  time  a  truss  spring  is  bent  its  pressure  is  somewhat 
reduced,  and  for  this  reason  it  is  best  to  start  with  a  spring  that 


TRUSS-FITTING. 

Fig.  73. 


159 


Shapings  truss  springs. 


160 


ABDOMINxlL  HERNIA. 


Shaping  truss  springs  {Continued'). 


TRUSS-FITTING.  161 

is  somewhat  stronger  tlian  needed.  Its  pressure  can  be  reduced 
by  taking  it  firmly  in  hand  rmd  stretching  out  (nos.  6  and  7, 
fig.  73),  or  bending  it  over  the  arm  of  a  chair.  Caution  is 
necessary  not  to  reduce  its  strength  too  much,  as  it  is  easier  to 
decrease  than  increase  it.  Its  pressure  may  Ije  increased,  how- 
ever, by  adding  to-  its  curves,  by  short,  firm  bends  between  tlie 
hands,  or  curHng  up  the  spring  as  shown  in  nos.  4  and  5,  fig. 
y^.  If  increase  of  pressure  obtained  this  way  is  considerable, 
it  will  be  to  quite  an  extent  transient,  and  it  is  usually  better  to 
exchange  for  a  stronger  spring.  It  is  to  be  rememljered  that 
all  hard-rubber  covered  springs  must  be  warmed  before  bend- 
ing, but  that  this  is  not  necessary  in  shaping  celluloid  or  leather 
covered  springs. 

Fig.  74. 


Hard-rubber  cross-body  truss  applied  to  complete  oblique  hernia.     In  sniiiU  hernia  the  pad 

may  be  higher. 

SELECTING    TRUSS. 

Oblique  Inguinal  Hernia. — An  incomplete  or  a  small  com- 
plete oblique  inguinal  hernia  is  usually  retained  by  a  very 
moderate  pressure  and  a  small  pad,  which  should  be  either 
directly  over  the  internal  ring  or  upon  the  canal  immediately 
beneath  that  point.  It  is  more  difficult  to  select  a  truss  exactly 
suited  to  the  treatment  of  a  small  hernia,  from  the  stock  of  the 
average  dealer,  than  it  is  for  a  large  hernia.  This  is  because 
many  dealers  will  have  nothing  to  do  with  a  light  truss  spring, 
believing  that  its  virtue  is  dependent  upon  its  strength.  Of  the 
11 


162 


ABDOMINAL  HERNIA. 


trusses  carried  in  stock  by  the  dealers,  few  will  be  found  better 
for  a  small  and  recent  hernia  than  a  light  spring  cross-body, 
preferably  with  a  hard-rubber  or  celluloid  covering  (nos.  2,  3, 
and  6,  cross-body  group).  If  the  spring  seems  too  strong, 
reduce  its  pressure  in  the  manner  already  described,  while 
shaping  it  to  the  diagram  of  the  patient.  When  applied  it 
should  occupy  the  position  shown  in  fig.  74,  or  still  better, 

Fig.  75. 


Woman  aged  40  years,  with  right  labial  hernia  of  seventeen  years'  duration. 

with  the  pad  a  little  higher.  The  pad  as  there  shown,  com- 
presses the  entire  canal,  while  in  a  small  oblique  hernia  it  is  only 
necessary  to  compress  its  upper  part.  The  higher  the  pad, 
with  retention  of  the  hernia,  the  greater  the  comfort  of  the 
wearer,  and  the  greater  will  be  the  improvement  obtained  from 
its  use.  Fig.  75  shows  a  large  labial  hernia  retained,  in  fig. 
"^^^  by  a  hard-rubber,  cross-body  truss.  The  pad  should  be 
about  no.  3  or  4  oval  (fig.  67)  and  moderately  convex.     Some 


TRUSS-IITTING. 


163 


manufacturers  make  what  they  caH  a  narrow-spring  cross-body, 
which  is  particularly  well  suited  to  light  cases. 

The  next  choice  in  such  a  case  would  be  a  light  Hood 
truss,  and  if  very  light,  is  to  be  preferred  even  to  the  cross- 
body  (fig.  'J'J^.  If  the  meager  stock  of  the  dealer  makes  it 
necessary  to  select  a  Chase  type  of  truss,  select  a  size  smaller 

Fig.  76. 


Right  labial  hernia  retained  by  hard-rubber  cross-body  truss. 


than  called  for  by  the  measure,  and  straighten  out  its  neck 
nearly  parallel  with  the  spring  (no.  3,  Chase  group),  and  shape 
by  diagram.  The  smaller  size  is  suggested  because  in  turning 
the  neck  nearly  parallel  with  the  spring,  the  latter  is  thereby 
lengthened.  Tlie  most  objectionable  feature  of  this  t3^pe  of 
truss  is  in  the  length  of  its  neck,  and  low  bearing  of  the  pad. 
If  driven  to  the  necessity  of  putting  on  a  truss  of  the  French  or 
elastic  type,  let  it  be  for  temporary  use  until  a  better  form  can 


164 


ABDOMINAL  HERNIA. 

Fig.  77.     • 


i"4/ 


Hard-rubber  steel-spring-  Hood  truss  with  pad  on  spiral  spring.  For  double  or  single 
hernia.  This  arrangement  of  pad  is  better  suited  to  fat  than  to  thin  people  and  where 
strong  pressure  is  required. 

Fig.  78. 


Complete  oblique  inguinal  hernia.    Recurrent  after  operation  by  MacEwen  method. 


TRUSS-FITTING. 


165 


be  obtained,  for  under  the  permanent  use  of  an  inferior  truss, 
small  hernia;  are  quite  sure  to  grow  worse.  Fig.  78  shows  an 
inguinal  hernia  in  a  woman  of  middle  life  that  would  require  a 
cross-body  spring  of  more  pressure,  or  what  was  believed  better 
in  this  case,  a  Hood  truss,  as  shown  in  fig.  79.  This  is  a 
very  light  form  of  the  Hood  truss  and,  in  some  cases,  might 

Fig.  79. 


Same   as  Fig.  78,  with  De  Garmo-Hood  truss  applied.    Hernia  is  perfectly  held  within  the 
abdomen.     Bulging  over  pubic  bone  is  from  a  thickened  sac  and  loose  skin. 

not  be  sufficiently  strong  to  retain  the  hernia  perfectly,  and  it 
would  be  well  to  use  the  regular  Hood  form  with  steel  springs, 
as  shown  in  fig.  yy. 

As  oblique  inguinal  hernia  increases  in  size  there  is  a  cor- 
responding shortening  of  the  canal,  by  the  dragging  down  of 
the  internal  ring,  until  it  is  nearly  opposite  the  external,  thereby 
increasing  the  difficulties  of  treatment.  Instead  of  having  a 
canal  an  inch  and  a  half  long  to  act  upon,  we  then  have  a  large 
hole  beneath  the  skin  leading  directly  into  the  abdominal  cavitv. 


166 


ABDOMINAL  HERNIA. 


In  addition  to  this  direct  opening,  there  is  usually  a  thickened 
sac,  in  these  neglected  cases,  that  also  prevents  in  a  measure  the 
efficient  action  of  a  truss.  Then  again  the  pad  must  rest  nearer 
the  pubic  bone,  and  this,  by  pressing  the  cord  or  other  tissues 
against  the  bone,  adds  seriously  to  the  discomfort  of  the  patient. 
Even  in  these  extreme  cases  the  Hood  truss  arranged  with  deep 

Fig.  So. 


Large  double  hernia.     Protrusion  on  the  left  not  complete  when  photograph  was  taken.    Size 
of  patient's  head  when  fully  out. 

pads  (fig.  yy)  is  an  excellent  truss.  Fig.  80  is  a  photograph 
of  enormous  double  scrotal  hernia,  which  was  retained  by  a 
Hood  truss  of  the  ordinary  type,  as  shown  in  fig.  81. 

In  order  to  clearly  comprehend  proper  and  inferior 
forms  of  truss,  it  is  advisable  to  compare  this  with  what  the 
Germans  call  a  "  Scrotal-Hemia  Truss.'  In  the  latter  there  is 
an  enormous  compress  over  the  pubic  bone  held  in  place  by  a 


TRUSS-FITTING. 


1G7 


strap  between  the  legs.  The  amount  of  pressure  necessary  to 
retain  the  hernia,  by  such  a  large  surface,  must  necessarily  be 
great.  In  these  enormous  hernice  I  have  for  many  years  held 
as  a  last  resort,  the  truss  known  as  the  "  Radical-Cure  Truss  " 
(nos.  4,  5,  and  7  of  cross-body  group).  This  will  many 
times  retain  a  hernia  upon  which  every  other  form  of  truss 

Fig.  81. 


Same  as  Fig.  80.     Hernia  retained  by  double  steel-spring  hard-rubber  Hood  truss. 

has  failed,  but  it  should  be  used  only  as  an  extreme  measure, 
as  it  is  most  uncomfortable.  Its  peculiarity  is  in  the  construc- 
tion of  the  retaining  pad,  which  has  a  small,  hard,  oblong 
centre,  surrounded  by  a  soft-rubber  or  kid-leather  ring.  In 
action  the  greater  amount  of  pressure  is  concentrated  upon  the 
small  central  pad,  and  to  this,  and  the  fact  that  they  are  usually 
made  with  an  especially  strong  spring,  is  to  be  attrilmted 
their  greater  retaining  power.     The  name  had  its  origin  in  the 


168  ABDOMINAL  HERNIA. 

fact  that  it  was  advertised  for  many  years  by  its  originator 
under  this  title.  That  it  possessed  any  special  virtues,  implied 
by  its  name,  is  not  believed,  except  that  it  retained  hernia 
securely  and  was  skillfully  applied  by  its  inventor.  Fig.  82 
shows  half  of  one  of  the  double  Radical-Cure  trusses  applied 
in  combination  with  half  of  an  ordinary  double  hard-rubber 
truss.  The  single  truss  should  always  be  of  the  cross-body 
type.  Some  makers  have  attached  this  pad  to  a  French  spring, 
but  this  combination  is  practically  worthless. 

Fig.  82. 


Hard-rubber  radical-cure   truss  on  right  side,   combined   with  ordinary  double 
hard-rubber  truss  on  left. 

In  fitting  these  large  and  neglected  cases,  it  must  be 
remembered  that  the  canal  is  destroyed,  and  that  the  point  of 
greatest  pressure  must  be  very  nearly  over  the  external  ring 
and  consequently  nearer  the  centre  of  the  abdomen  than  it 
would  be  applied  in  small  oblique  hernia.  In  many  of  these 
large  hernise  the  use  of  the  water  pad,  which  can  be  combined 
with  any  form  of  spring,  will  be  found  to  retain  better  than 
the  smooth,  hard  pad.  When  the  water  pad  is  used,  it  should, 
if  possible,  be  changed  to  the  hard  pad  as  soon  as  sufficient 
improvement  warrants  it,  for,  while  valuable,  they  are  not 
very  durable  and  therefore  need  to  be  watched.     Under  proper 


TRUSS-FITTING.  16» 

treatment,  that  is,  perfect  retention  and  gradual  reduction  of 
pressure,  large  oblique  herniee  improve  in  almost  every  instance. 
Ill  is  improvement  is  sometimes  so  great,  that  if  the  patient 
allow^s  a  protrusion  of  the  hernia,  he  may  be  unable  to  reduce 
it,  and  serious  results  ensue.  Patients  under  treatment  for 
large  hernicC  must  be  particularly  cautioned  regarding  this 
danger,  and  advised  never  to  stand  without  a  truss  on. 

In  the  Author's  experience  there  have  been  very  few 
reducible  hernise,  even  of  enormous  proportions,  that  could  not 
be  cfjntrolled  by  a  suitable  truss  properly  adjusted,  and  he  has 
relied  largely  upon  either  the  Hood  form  or  cross-body  spring, 
with  such  variations  of  pad  as  seemed  to  be  required  by  the 
peculiarities  of  the  case.  The  retention  of  these  herni^e  must 
be  undertaken  seriously,  and  not  considered  as  trifling  cases  to 
which  a  truss  can  be  applied  and  the  patient  sent  away.  It  has 
frequently  happened  that  patients,  coming  from  a  distance, 
have  been  sent  away  unattended  until  such  time  as  they  could  be 
given  the  uninterrupted  attention  necessary  to  successful  treat- 
ment. This  course  might  entail  a  delay  of  from  five  to  ten 
days,  or  longer,  with  the  patient  in  bed  part  of  the  time, 
if  retention  could  only  be  accomplished  in  the  recumbent  posi- 
tion. Cases  of  this  type  that  had  previously  met  with  repeated 
failure,  managed  in  this  way,  have  had  the  most  gratifying 
results.  It  is  true,  now  that  the  surgical  treatment  of  these 
cases  is  so  successful,  that  there  is  not  the  incentive  to  this 
persistent  and  hard  work  as  in  former  years;  still,  there  may 
be  good  reasons  why  an  operation  is  not  advisable,  and  they 
should  under  no  circumstances  be  abandoned  as  hopeless. 

When  these  enormous  hernise  are  reduced  and  retained,  in 
the  male  sex,  there  remains  a  large  mass  of  thickened  sac  and 
fascia  as  well  as  elongated  cords  and  scrotum.  It  aids  greatly 
in  the  retention  of  the  hernia  and  adds  much  to  the  comfort  of 
the  patient,  to  adjust  a  firm  and  tight-fitting  suspensory 
bandage.  In  people  who  have  large,  pendulous  abdomens  and 
flabby  muscular  walls,  a  light,  but  strong,  abdominal  belt  will 
aid.     Such  belts  are  usually  kept  in  stock  by  dealers,  but  it  is 


170 


ABDOMINAL  HERNIA. 


far  better,  when  possible,  to  have  them  made  to  order,  as  they 
usually  contain  rubber,  which  material  rapidly  deteriorates 
when  lying  unused.  A  group  of  these  belts,  and  directions  for 
measuring,  will  be  found  in  the  chapter  on  the  mechanical  treat- 
ment of  umbilical  hernia. 

The  English  use,  for  cases  of  very  large  hernise,  what 
they  term  the  "  Rat-Tail  Truss"  (fig.  83).     It  will  be  noted 

Fig.  83. 


English  "  Rat-tail  "  truss.     {Macready.) 


that  this  truss  is  c|uite  similar  to  the  French  type,  except  that 
it  is  vastly  superior  in  that  the  direction  of  the  pad  is  nearly 
continuous  with  the  spring,  bringing  it  directly  over  the  canal, 
instead  of  over  the  pubic  bone  as  in  the  German  truss.  The 
spring  in  this  truss  is  also  long  enough  to  clasp  the  opposite 
hip,  which  greatly  aids  in  holding  it  firmly  in  place.  It  is  to  be 
hoped  that,  eventually,  our  truss  makers  will  abandon  the  pat- 
terns now  used  for  making  the  French-German  type  and  adopt 
those    more   nearly    approaching   the    English    design.      The 


TRUSS-FITTING. 


171 


advantages  of  the  Eng-lish  truss  arc  well  shown  in  fig.  84,  as 
api)lie(l  to  (lonble  inguinal  hernia;  we  believe,  however,  that 
with  accurate  fitting  of  the  spring,  the  understraps,  which  are 
always  objectionable,  could  usually  be  abandoned,  and  we  can 
speak  in  praise  of  the  position  of  the  pads  only.  In  contrast 
to  this,  attention  is  called  to  a  truss  of  the  same  type  (fig.  85), 

Fig.  84. 


An  English  type  of  double  truss,  applied.     {Eccles.) 


very  extensively  sold  in  this  country,  which,  while  excellent  in 
construction,  has  the  serious  defect  of  having  the  centre  of  the 
pad  too  far  below  the  spring.  This  truss,  as  shown  applied,  is 
in  very  good  position,  except  that  the  spring  is  too  high. 
When  the  wearer  stoops,  the  abdomen  strikes  the  upper  edge  of 
the  spring,  and  forces  the  pad  down  over  the  pubic  bone. 


172  ABDO:\riXAL  HERNLA.. 

Direct  Inguinal  Hernia. — The  mechanical  treatment  of 
direct  hernia  is,  in  most  respects,  similar  to  that  of  the  oblique 
variety,  except  that  the  difficulties  are  somewhat  increased  on 
account  of  its  close  proximit}^  to  the  pubic  bone.  The  con- 
tents of  a  direct  hernia  may  sometimes  account  for  truss-wear- 
ing being  m.ore  painful.  In  direct  hernia  we  may  have  the 
bladder,  cjecum,  or  sigmoid  flexure,  forming  part  or  all  of  the 
protrusion.  In  such  a  case  pain  is  caused  by  direct  truss- 
pressure  upon  the  bladder  or  bowel.      Several  cases  of  sigmoid 

Fig.  85. 


Hard-rubber  French  type  of  truss  applied.  The  strap  may  be  buttoned  on  stud-head 
at  end  of  spring  or  on  another  below  centre  of  pad.  The  latter  is  preferred.  The  tendency 
of  this  truss  is  to  slip  down  over  the  pubic  bone. 

and  cjecal  hernia  have  been  seen,  that  could  not  tolerate  any 
form  of  truss  pressure  that  was  sufficient  to  retain  the  protru- 
sion. In  direct  hernia  a  pad  that  is  nearly  circular  in  shape  is 
frequently  better  than  the  oblong  form.  The  water  pad  is  par- 
ticularly good,  for,  even  if  some  pressure  is  made  against  the 
pubic  lx)ne,  it  does  not  cause  the  pain  that  a  hard  pad  would. 
\\'hatever  pad  is  used  it  must  be  placed  nearer  the  median  line, 
and  lower,  than  for  oblique  hernia.  Little  or  no  improvement 
must  be  expected  in  direct  hernia  from  truss-wearing.  If  the 
case  is  prevented  from  increasing  in  size  and  the  patient  is  made 
fairly  comfortable,  it  must  be  looked  upon  as  successful. 


TRUSS-FITTING.  173 

COMPLICATIONS. 

There  are  certain  complications  met  with  in  the  mechanical 
treatment  of  hernia  that  require  special  consideration,  and 
notably  are  the  following : 

(i)  Cysts,  within,  or  just  outside  the  canal. 

(2)  Elongated  sub-peritoneal  fat. 

(3)  Reducible  hydrocele  or  other  fluid  in  sac. 

(4)  Varicocele. 

(5)  Delayed  descent  of  testicle. 

(6)  Interstitial  hernia. 

(7)  Pregnancy. 

(8)  Adhesions  of  hernial  contents. 

Cysts. — It  is  not  very  uncommon,  and  may  occur  in  either 
sex,  that  cysts  form  within  the  canal  or  in  the  vicinity  of  the 
external  ring,  where  they  interfere  seriously  with  truss-wearing 
and  lead  to  doubts  as  to  diagnosis.  Those  that  form  lower 
down  on  the  cord,  or  in  front  of  the  testicle,  are  not  now  under 
consideration,  as  they  are  sufficiently  far  away  from  the  canal 
to  escape  truss  pressure.  These  cysts  most  commonly  form  in 
that  part  of  the  tunica  vaginalis  which  occupies  the  canal  and 
which  has  not  been  completely  obliterated.  They  may  be 
closely  associated  with  the  cord  (or  round  ligament),  or  hang 
by  a  pedicle,  so  as  to  slip  out  of  the  canal  and  have  the  appear- 
ance of  being  reducible  to  the  abdominal  cavity.  It  is  the  latter 
type  that  prove  the  most  troublesome  and  misleading  in  the 
mechanical  treatment  of  hernia.  They  may  be  associated  with 
hernia,  or  occur  alone  and  be  mistaken  for  the  latter  condition. 
Their  recognition  is  usually  not  difficult,  if  their  possible  occur- 
rence is  kept  in  mind.  If  a  round,  somewhat  elastic  tumor 
repeatedly  slips  under  the  truss  pad,  it  is  in  all  probability  either 
one  of  these  cysts,  a  piece  of  hypertrophied  omentum,  or  sub- 
peritoneal fat.  While  the  cysts  present  a  round,  elastic  surface, 
that  of  omentum  or  sub-peritoneal  fat  is  usually  nodular,  and 
its  connecting  neck  is  larger  than  the  pedicle  of  a  cyst.  Further- 
more, if  the  patient  is  lying  down,  omentum  is  fully  reducible 


174  ABDOMINAL  HERNIA. 

to  the  abdomen,  and  the  cysts  wiU  appear  to  be  reduced,  yet 
deep  pressure  over  the  canal  AviH  reveal  their  presence. 

The  treatment  of  such  cases  must  depend  largely  upon  the 
position  of  the  cysts.  If  in  the  way  of  the  truss  pad,  it  is  best 
to  draw  the  fluid  off.  Frequently  this  can  be  done  by  a 
hypodermic  needle,  but  if  they  are  large,  an  aspirating  needle 
will  be  better.  It  has  been  my  habit  to  make  no  further  attempt 
to  cure  them  on  the  first  tapping,  as  this  alone  is  sufficient  in 
many  instances.  If  they  reform,  they  are.  upon  the  occasion  of 
the  second  tapping,  injected,  through  the  same  needle  that  has 
been  used  for  drawing  off  the  fluid,  with  from  five  to  ten  drops 
of  95  per  cent,  pure  phenol.  On  the  day  following  this 
injection,  there  will  be  a  recurrence  of  the  fluid,  almost,  if  not 
quite,  equal  to  the  original  quantity.  By  the  fifth  day  their 
absorption  will  be  noticeable,  and  by  the  tenth  to  fourteenth 
day  it  will  usually  be  complete,  and  the  cure  of  the  cysts  perma- 
nent. If  these  cysts  drop  so  far  below  the  truss  pad  as  to 
cause  no  discomfort,  they  may  be  entirely  ignored,  as  they 
seldom  acquire  sufficient  size  to  be  inconvenient ;  but  if  within 
the  canal,  they  are,  by  their  distention  of  the  tissues,  a  positive 
injury,  besides  causing  the  patient  a  great  amount  of 
discomfort. 

Sub-peritoneal  fat  is  often  a  forerunner  of,  or  associated 
with,  inguinal  hernia.  During  muscular  action  it  is  pressed 
into  the  canal  from  in  front  of  the  peritoneum,  and  in  this 
position  it  becomes  elongated,  so  that  it  may  protrude  at  the 
external  ring.  It  is  entirely  outside  of  the  hernial  sac,  if  one 
exist,  and  to  the  average  observer  it  cannot  be  distinguished 
from  protruding  omentum.  Its  action  under  truss-pressure  is 
very  similar  to  that  of  a  fluid  cyst ;  it  will  persistently  slip  from 
under  the  truss-pad  and  lead  the  patient,  and  probably  also  the 
doctor,  to  believe  that  it  is  the  hernia  that  protrudes.  Its  feel- 
ing and  shape  are  quite  different  from  that  of  a  cyst.  It 
remains  in  the  canal  when  the  patient  is  lying  down,  and  careful 
examination  will  usually  reveal  this  condition.  It  cannot 
ordinarily  be  differentiated  from  omentum  adherent  within  the 


TRUSS-FITTING.  17.5 

sac.  The  truss  pad  can  be  worn  over  it  without  harm,  and  in 
many  instances  this  pressure  will  result  in  its  absorption.  If 
recognized,  it  is  best  to  assure  the  patient  that  no  harm  will 
come  from  it,  even  though  it  does  protrude  from  beneath  the 
truss.  It  is,  of  course,  better  that  it  should  be  held  within  the 
canal  in  the  hope  that  it  will  be  destroyed,  but  this  cannot 
always  be  accomplished.  The  absorption  and  disappearance  of 
this  fat,  under  truss  pressure,  would  doubtless  account  for  some 
of  the  apparently  remarkable  cures  of  hernia  in  the  adult  by 
truss- wearing.  In  such  cases  the  fat  is  present,  but  there  is  no 
hernial  sac.   In  other  words,  no  hernia  exists. 

Reducible  Hydrocele  or  other  fluid  in  the  sac.  The  con- 
dition of  reducible  or  congenital  hydrocele  is  not  a  very 
common  one,  and,  as  mig"ht  be  expected,  is  seldom  found  except 
in  children.  Its  recognition  is  the  most  important  part,  as  \'ery 
little  modification  will  be  necessary  in  the  mechanical  treatment. 
Where  free  fluid  exists  in  the  hernial  sac  no  amount  of  truss 
pressure  will  retain  it  within  the  cavity  of  the  abdomen.  For- 
tunately, this  condition  is  usually  temporary,  and  if  the  truss 
pressure  is  maintained  in  order  to  retain  the  hernia,  it  will 
usually  right  itself.  It  is  cpiite  inadvisable  to  resort  to  any 
method  but  that  of  an  operation  for  the  cure  of  existing  hernia 
and  the  destruction  of  the  secreting  membrane.  It  is  seldom 
advisable  to  tap  the  hydrocele,  and,  wdien  this  is  done,  it  must 
be  remembered  that  in  reality  the  cavity  of  the  abdomen  is 
being  entered,  and  every  precaution  as  to  asepsis  should  guard 
the  patient  against  infection. 

Free  fluid  in  the  cavity  of  the  abdomen  (ascites)  from 
heart,  kidney,  liver  or  other  lesions,  is  a  very  troublesome  com- 
plication in  the  mechanical  treatment  of  inguinal  hernia,  and 
frequently  causes  the  patient  greater  mental  concern  than  the 
possibly  fatal  malady  which  is  its  cause.  It  is  entirely  futile 
to  attempt  the  retention  of  such  fluid  by  truss  pressure.  If  it  is 
not  large,  truss-wearing  should  be  continued  in  order  to 
prevent  the  protrusion  of  bowel  or  omentum,  and  the  patient 
should  be  assured  that  no  harm  will  come  from  the  fluid  in  the 


176  ABDOMINAL  HERNIA. 

sac.  If  the  abdominal  distention  is  great,  it  is  really  unim- 
portant whether  the  patient  wears  a  truss  or  not,  as  the  bowel 
and  omentum  both  float  at  the  upper  abdominal  cavity  on  the 
fluid,  and  there  is  no  tendency  for  either  to  protrude  through 
the  inguinal  canal.  A  large  and  strong  suspensory  bag  affords 
about  the  only  approach  "to  comfort  that  can  be  afforded. 
Ascites,  following  scarlet  fever  or  from  other  causes,  should  be 
managed  in  the  same  general  way,  except  that  it  is  more 
important,  in  these  cases,  to  continue  the  use  of  the  truss  even 
though  a  large  quantity  of  fluid  is  present.  When  this  fluid  is 
reabsorbed,  it  may  require  temporarily  increased  truss  pressure 
on  account  of  the  damage  done  the  abdominal  wall  by  over- 
distention,  but  as  the  case  improves  the  pressure  should  be 
again  diminished. 

Varicocele. — The  small  or  moderate  size  varicocele 
demands  little  attention  in  the  mechanical  treatment  of  inguinal 
hernia,  except  to  keep  in  mind  the  fact  that  compression  of  the 
cord,  against  the  pubic  bone,  will  retard  the  return  flow  of 
venous  blood  from  the  testicle  much  more  than  it  will  obstruct 
the  arterial  supply,  so  that  poor  truss-fitting  tends  decidedly  to 
increase  the  condition.  A  large  varicocele,  combined  with 
hernia,  requires  the  use  of  a  snug-fitting  suspensory  in  addition 
to  the  truss.  It  will  also  make  necessary  the  resorting  to 
stronger  spring  pressure,  as  the  cord  is  almost  always  much 
larger  than  normal.  Various  special  pads  have  been  designed, 
so  made  as  to  press  on  either  side  of  the  canal  and  avoid 
extreme  pressure  on  the  cord,  but  they  are  of  little  real  ser- 
vice. A  small  pad  placed  high  on  the  canal  will  protect  the 
cord  better  than  any  other  way  known  to  the  Author. 

Delayed  Descent  of  Testicle. — This  condition  complicates, 
perhaps,  more  frequently  than  any  other,  the  mechanical  treat- 
ment of  hernia.  It  is  not  uncommon  in  children  that  the 
absence  of  the  testicle,  from  the  scrotum,  remains  undiscovered 
by  parents  until  bulging  in  the  inguinal  region  is  noticed.  This 
bulging  indicates  the  attempts  of  the  testicle  to  get  into  its 
normal  position,  and  it  is  safe  to  state  that  it  is  always  accom- 


TRUSS-FITTING.  177 

panied  by  hernia,  and,  that  the  hernia  occupies  a  congenital  sac. 
In  view  of  these  facts,  it  is  a  condition  worthy  of  the  most 
careful  attention  at  whatever  period  in  hfe  it  is  discovered. 

It  is  obviously  the  duty  of  the  physician  to  so  treat  the 
case,  if  possible,  as  to  aid  the  attempts  of  nature  to  place  the 
testicle  in  the  scrotum,  and  to  this  end  the  truss  should  be  so 
adjusted  as  to  retain  the  hernia  without  preventing  the  descent 
of  the  testicle.  If  the  patient  is  very  young,  the  bulging  slight, 
and  the  testicle  not  outside  the  canal,  it  is  considered  good 
practice  to  keep  the  case  under  observation,  but  to  apply  no 
truss.  As  the  hernia  increases  in  size,  both  it  and  the  testicle 
will  protrude  at  the  external  ring,  and  they  may  then  l^e 
separated ;  the  former  retained  by  a  small  pad  over  the  upper 
part  of  the  canal,  while  the  testicle  is  kept  from  re-entering  the 
canal,  from  below,  by  the  same  pad.  The  preferred  spring,  for 
these  cases,  is  of  the  cross-body  type,  (no.  3, cross-body  group), 
as  light  as  possible,  and  to  this  should  be  attached  a  small, 
prominent  pad  the  size  of  no.  3  or  4  of  the  oval  pad  diagram 

(fig- 67). 

If  a  truss  of  this  type  can  be  worn  with  comfort,  it  is 
advisable  to  continue  its  use  for  tw^o  or  more  years,  in  children 
under  five  years  of  age.  If,  however,  it  causes  any  amount  of 
pain,  especially  colicky  pain  in  the  abdomen,  this  indicates  that 
the  intestine  is  not  fully  reducible  and  the  use  of  the  truss 
should  be  discontinued.  Such  cases  are  unsuitable  for 
mechanical  treatment  and  operation  is  advisable  at  the  earliest 
date  convenient.  Even  where  reduction  and  retention  are 
complete,  cases  of  hernia,  associated  with  delayed  descent  of 
the  testicle,  are  very  seldom  cured  by  truss  treatment,  as  the 
congenital  sac  in  communication  with  the  testicle  persists,  and 
it  is  believed  that  they  are  properly  operative  cases.  The 
only  reasonable  excuse  for  delay  is,  perhaps,  the  early  age  or 
bad  general  condition  of  the  patient. 

^^^^ere  the  testicle  is  retained  high  in  the  canal,  associated 
with  troublesome  hernia  of  good  size,  some  relief  and  protec- 
tion against  strangulation  of  the  intestine  may  be  obtained  by 

12 


178 


ABDOMINAL  HERNIA. 


using,  after  reducing  the  protrusion,  a  soft  water  pad  directly 
over  the  testicle.  A  concave  pad  and  one  made  in  horseshoe 
shape  have  been  used  with  at  least  partial  success.  The  wear- 
ing of  any  pad  that  presses  directly  upon  the  testicle  is, 
however,  attended  by  more  or  less  discomfort  and  aids  in  the 
destruction  of  the  already  impaired  organ.     That  it  leads  to 

Fig.  86. 


Double  retained  testes  associated  with  double  congenital  hernia. 


cancer  of  the  testicle,  as  stated  by  some  writers,  has  not  been 
borne  out  by  the  author's  experience.  A  testicle  may  be 
permanently  retained  within  the  canal  by  truss  pressure,  but  if 
there  is  sufficient  length  of  cord  to  allow  of  it,  slipping  beneath 
the  truss  pad  is  pretty  sure  to  occur,  and  at  such  times  is  liable 
to  produce  the  most  excruciating  pain. 

In  the  case  illustrated  in  fig.  (S6  a  young  married  man  of 
twenty-eight  years  of  age  had  enjoyed  perfect  health  in  every 


TRUSS-FITTING.  179 

respect  except  the  defect  under  consideration.  Both  testicles 
were  retained  within  the  canals.  At  times  one  or  hoth  wcnild 
slip  outside  the  external  rint^-  and  he  would  then  suffer  extreme 
torture  until  he  was  able  to  reduce  them  to  the  canal.  On  the 
other  hand,  if  he  abandoned  truss-wearing-,  he  was  subject  to 
symptoms     of     strangulated     hernia.      Between     these     two 

Fig.  87. 


M 


Double    retained    testes.     Same    as    Fig.    S6    with     truss     removed.     Showing    effects    of 

extreme  pressure. 

dilemmas  he  found  truss-wearing  the  safer,  and  the  truss  shown 
on  him  seemed  to  be  the  best  for  his  use.  Examination  of  the 
photograph,  with  the  truss  removed  (fig.  87),  shows  the  result 
of  the  extreme  pressure  necessary  to  retain  the  testicles  within 
the  canals.  This  case  was  suhse(|uently  operated  upon.  De- 
layed testes  may,  in  some  few  instances,  be  retained  in  the  canal 
under  truss  pressure  for  years  with  comparatively  little  trouble, 
and  then  become  so  irritable  as  to  necessitate  the  abandonment 


180  ABDOMINAL  HERNIA. 

of  the  support.  One  patient,  sixty  years  of  age,  had  through- 
out his  hfe  worn  a  truss  that  retained  the  testicle  in  the  canal, 
but  the  organ  finally  persisted  in  slipping  under  the  pad  and 
eventually  descended  into  the  top  of  the  scrotum  at  that  late 
period  in  life.  A  small,  deep  truss  pad  was  adjusted  so  as  to 
compress  the  upper  part  of  the  canal,  retaining  the  hernia  and 
thereby  securing  safety  and  comfort. 

Descent  of  the  ovary  into  or  through  the  inguinal  canal 
complicates,  more  rarely,  the  mechanical  treatment  of  inguinal 
hernia.  It  carries  with  it  the  same  form  of  congenital  sac  and 
the  same  difficulties  of  treatment.  It  forms  a  mass  in  the 
canal  which  is  hard  to  diagnose  from  adherent  omentum.  If 
the  ovary  is  present  the  mass  will  usually  at  each  period  of 
menstruation  become  larger  and  more  sensitive  to  pressure. 

As  regards  pain,  truss  pressure  is  better  tolerated  in  these 
cases  than  where  the  testicle  is  similarly  placed,  and  in  several 
instances  a  small  truss  pad  has  been  worn  over  the  upper  part  of 
the  canal,  retaining  the  hernia  wdiile  the  ovary  has  been  protrud- 
ing at  the  external  ring.  In  two  or  three  cases  a  concave  pad 
has  been  used  directly  over  the  ovary,  retaining  the  hernia 
without  any  amount  '  of  discomfort.  One  patient,  under 
observation  for  twenty  years,  has  been  obliged  to  remove  her 
truss  at  each  menstrual  period,  but  suffers  no  discomfort  at 
other  times,  and  has  declined  operative  relief.  An  ovary  that 
has  once  entered  the  canal  is  seldom  again  fully  reducible  to  the 
abdomen,  and  it  is  quite  likely  to  become  diseased  in  this 
abnormal  position,  especially  when  under  truss  pressure,  and 
for  this  reason  it  is  considered  best  to  look  upon  them  as 
operative  cases  unless  especially  contra-indicated  by  some  other 
more  serious  condition. 

Interstitial  hernia  instead  of  following  the  canal  and 
descending  into  the  scrotum  or  labium,  forms  a  sac  for  itself 
between  the  layers  of  the  abdomen,  and  while  it  usually  pre- 
sents a  tumor  covering  a  large  area,  its  contents,  if  reducible, 
are  returned  to  the  abdominal  cavity  through  a  comparatively 
small  opening  at  the  internal  ring.      Personal  experience  leads 


TllUSS-llTTING. 


181 


to  the  l)elief  that  ahiiost  any  of  the  trusses  used  for  obH(|ue 
inguinal  hernia  will  be  ecjually  successful  in  this  condition. 

The  English  prefer  in  these  cases  a  larger  pad  such  as 
shown  in  fig.  88,  but  the  water  pad  of  medium  si;^e  on  either 
the  cross-body  or  Hood  spring  has  been  found  less  cumbersome, 
and  is  believed  to  be  more  effective.  Owing  to  the  peculiar 
formation   of   the   sac   in   interstitial    hernia   there   is   greater 

Fig.  88. 


Truss  for  reducible  interstitial  hernia.    {Macready.) 


liability  to  the  occurrence  of  strangulation,  and  unless  the 
retention  by  truss  pressure  is  complete  at  all  times,  early  opera- 
tion for  cure  should  be  strongly  advised. 

Pregnancy  presents  complications  in  the  mechanical  treat- 
ment of  hernia  that  should  be  considered.  In  the  earlier  months 
difficulty  in  retaining  the  henn'a  is  increased  by  intra-abdominal 
pressure,  and  it  is  frequently  necessary  to  add  spring  pressure. 
Later,  this  pressure  should  be  removed  and  the  size  of  truss 
increased. 


182  ABDOMINAL  HERNIA. 

As  pregnancy  advances  and  the  uterus  rises  up  out  of  the 
pelvis,  it  carries  the  intestines  and  the  omentum  higher  in  the 
abdominal  cavity  and  away  from  the  inguinal  region.  It  there- 
fore commonly  happens  that  a  woman  could  with  safety 
abandon  her  truss  entirely  during  the  last  six  weeks  of  gestation 
without  suffering  any  protrusion  of  her  hernia.  It  is  not  con- 
sidered best  that  this  should  be  done,  as  a  very  light  truss  can 
be  worn  with  safety.  The  disappearance  of  the  hernia  during 
the  last  months  of  pregnancy  has  frequently  led  both  the  patient 
and  the  doctor  to  believe  that  it  had  been  cured,  and  conse- 
quently into  the  mistake  of  allowing  the  woman  to  get  out  of 
bed  during  her  convalescence  without  having  her  truss  on. 
This  is  fraught  with  special  danger  at  this  time,  when  the 
muscles  are  weak  and  flabby  from  recent  distention.  The  truss 
should  be  very  carefully  readjusted  before  the  woman  leaves 
the  bed. 

Adhesions  of  Hernial  Contents  to  Sac  Wall. — These  cases 
will  be  more  fully  considered  under  the  heading  of  irreducible 
hernia,  and  reference  here  is  to  those  cases  only  where  the  bulk 
of  the  protrusion  is  reducible,  but  a  small  part,  usually 
omentum,  is  held  in  the  hernial  sac  by  adhesion. 

This  condition  is  not  always  recognized  by  examining  the 
hernia,  but  may  be  first  suspected  by  the  extreme  difficulty 
experienced  in  retaining  it  by  the  truss  applied.  In  most  cases 
where  a  hernia  of  moderate  size  cannot  be  retained  by  means 
of  a  well-fitting  truss,  there  probably  is  a  small  piece  of  adherent 
omentum  within  the  canal  that  is  not  reducible.  After  the 
truss  is  applied  this  omentum  acts  as  a  guide  or  actually  drags 
down  the  bulk  of  the  hernia.  If  the  adherent  part  is  omentum, 
no  harm  will  come  of  wearing  strong  pressure  across  it,  and 
eventuallv  this  will  destroy  it  and  the  hernia  become  easily 
manageable  by  a  truss  of  ordinary  pressure.  It  is  best,  there- 
fore, to  start  with  as  strong  a  pressure  as  can  be  tolerated,  and 
the  patient  should  be  instructed  to  reduce  the  hernia  as  soon  as 
he  feels  that  it  has  protruded  under  the  truss  pad.  The  so-called 
"  Radical-Cure  Truss  "  has  been  found  most  frequently  sue- 


TRUSS-FITTING.  183 

cessful  (cross-body  group,  fig.  no.  4),  and  a  night  truss  is 
desiralMe.  For  the  latter  purpose  nothing  has  been  found 
better  than  the  elastic  truss  shown  in  the  group  of  spring- 
less  trusses.  The  day  truss  should  be  applied  before  the 
patient  leaves  the  bed  in  the  morning  and  after  careful  reduc- 
tion of  the  hernia.  The  change  to  the  night  truss  should  be 
after  the  patient  is  in  bed.  In  using  extreme  truss  pressure  the 
skin  must  be  thoroughly  cleansed  twice  daily  and  kept  dry  with 
some  good  antiseptic  or  talcum  toilet  powder.  If  bowel  is 
adherent  to  the  sac  wall  it  will  be  found  that  strong  truss  press- 
ure cannot  be  tolerated.  Colicky  pains  will  be  experienced 
similar  to  those  in  threatened  strangulation,  more  frequently 
in  the  vicinity  of  the  navel  than  under  the  truss  pad,  and 
truss-wearing  should  be  at  once  abandoned  and  operative  relief 
afforded. 

MECHANICAL  TREATMENT  OF  IRREDUCIBLE 
INGUINAL  HERNIA. 

It  is  not  necessary  to  devote  much  space  to  this  branch  of 
the  subject,  as  the  proper  treatment  of  irreducible  hernia  is  by 
surgical,  instead  of  mechanical  means.  There  are  cases,  how- 
ever, where  from  one  cause  or  another  operation  is  inadvisable 
and  then  the  question  of  palliative  treatment  must  be  met.  The 
older  works  on  hernia  taught  that  it  was  dangerous  to  wear  a 
truss  pad  over  protruding  omentum.  Experience  has  so  often 
disproven  the  correctness  of  this  statement  that  it  can  be  flatly 
contradicted.  The  protruding  contents  of  an  irreducible 
inguinal  hernia  are  almost  always  omentum  and  intestine ;  the 
latter  being  reducible,  and  the  former  adherent  to  the  sides  or 
bottom  of  the  hernial  sac.  Such  a  case  is  shown  in  the  photo- 
graph, fig.  89.  Where  the  intestine  is  reduced  it  can,  in  many 
instances,  be  retained  by  strong  truss  pressure  across  the  neck 
of  omentum,  wdiere  it  passes  through  the  canal.  Such  pressure 
may  protect  the  patient  against  strangulated  bowel.  The 
inconvenience  that  he  will  suffer  will  usuallv  be  that  attendant 


184 


ABDOMINAL  HERNIA. 


upon  the  wearing  of  an  unusually  strong  truss.  It  seldom 
happens  that  pressure  upon  the  neck  of  omentum  does  any- 
serious  harm,  and  in  exceptional  cases  it  has  caused  its  absorp- 
tion. In  rare  instances  an  inflammatory  action  has  been  set 
up,  necessitating  confinement  to  bed  and  application  of  an  ice- 
bag  for  twenty-four  or  forty-eight  hours,  but  nothing  more 

Fig.  89. 


Large  irreducible  scrotal  hernia.  Intestine  wholly  reducible  and  could  be  retained  by 
truss  pressure.  Subsequently  cured  by  operation  ;  large  mass  of  hypertrophied  omentum 
amputated. 

serious  has  been  seen.  The  case  is  certain  to  grow  worse, 
even  though  protected  against  the  dangers  of  strangulated 
hernia.  The  protruding  omentum  becomesi  hardened  and 
takes  on  a  condition  of  hypertrophy  which  may  lead  to  its 
development  to  an  enormous  size. 

In  selecting  a  truss  for  these  cases  a  strong  spring  must 
be  used,  usually  of  the  cross-body  variety  of  the  ordinary  type, 
or,  still  better,  the  radical-cure  form.  The  water  pad,  aside  from 


TRUSS-IITTING. 


185 


the  fact  that  it  is  not  durable,  is  a  very  g-ood  one.  Many  times, 
however,  a  deep  hard-rubber  pad,  of  good  size,  may  be  worn 
with  equal  comfort  and  prove  far  more  serviceable.  If  the 
irreducibility  of  the  hernia  is  caused  by  adherent  omentum  in 
the  canal,  that  does  not  extend  down  to  the  scrotum  and  is 
small  in  quantity,  then  a  concave  pad  will  prove  useful.  In 
these  smaller  cases  it  is  not  uncommon  for  the  adhesions  to 

Fig.  90. 


The  hinged-cup  truss  for  irreducible  hernia.    (Macrcady.  > 


yield  under  the  pressure  of  the  truss  and  the  hernia  to  become  a 
reducible  one.  In  such  a  case,  where  a  concave  pad  has  been 
used,  it  should  promptly  be  changed  to  a  convex  one,  in  order 
to  secure  more  perfect  retention.  The  convex  pad  should  be 
applied  in  every  case  where  the  protrusion  can  be  reduced  into 
the  canal  and  is  of  small  size. 

Where  a  mass  of  omentum  is  adherent  in  the  scrotum,  and 
a  truss  pad  has  been  applied  across  its  neck,  a  good-fitting. 


186 


ABDOMINAL  HERNIA. 


strong  suspensory  bandage  should  also  be  constantly  worn. 
The  English  use  what  they  term  a  "  Hinged-Cup  Truss  "  (fig. 
90),  which  appears  to  combine  the  pressure  of  a  regular  truss 
pad  with  a  concave  cup  over  the  protruding  omentum. 
Macready  says  of  it: 

Fig.  qi. 


Enormous  irreducible  left  scrotal  inguinal  hernia.       Both  intestine  and  omentum  irreducible. 


"  It  is  seen  to  consist  of  two  parts,  of  which  one  occupies 
very  nearly  the  position  of  the  pad  of  an  ordinary  truss  and  is 
not  concave,  and  the  other  forms  a  scrotal  portion,  which  is 
united  to  the  former  by  a  transverse  hinge.  The  scrotal  part  is 
a  three-sided  frame  of  metal,  covered  in  with  chamois  leather, 
curved  to  adapt  itself  to  the  distended  scrotum.  The  apex  of 
the  triangle  is  downwards  towards  the  perineum,  and  to  it  are 
attached  the  understraps,  which  are  fastened  to  the  side  of  the 


TRUSS-FITTING. 


187 


truss  just  behind  the  shoulder,  as  usual.  Every  pull  on  the 
understrap  presses  the  cup  against  the  scrotum,  whilst  by  means 
of  the  hinge,  the  movement  is  hindered  from  being  conveyed  to 
the  pad."     The  author  has  had  no  personal  experience  with  it. 

F:g   92. 


Showing  method  of  supporting  enormous  irreducible  scrotal  hernia,  when  no  form  of  truss 
can  be  worn.    The  weiglit  is  transferred  to  the  shoulders  by  a  pair  of  suspenders. 

Irreducible  scrotal  hernia  of  enormous  proportions,  such 
as  is  shown  in  fig.  91,  in  which  truss-wearing  is  impossible,  and 
when  operation  is  inadvisable,  should  be  protected  by  especially 
constructed  supporting  bags  (fig.  92).  The  bag  should  be 
made  from  measures  carefully  taken,  while  the  patient  is 
recumbent  and  with  the  tumor  at  its  smallest.  There  should  be 
a  strong  band  about  the  pelvis  to  which  can  be  buttoned  an 


188  ABDOMINAL  HERNU. 

ordinary  pair  of  non-elastic  suspenders  passing  over  the  shoul- 
ders. A  support  of  this  kind  will,  in  a  measure,  prevent 
increase  in  size  besides  adding  materially  to  the  comfort  of  the 
sufferer.  Such  hernise  are  pretty  sure  to  cause  the  death  of  the 
patient  eventually,  and  their  operative  relief  should  be  seriously 
and  immediately  considered.  It  is  true  that  danger  attends 
such  operations,  but  it  must  also  be  taken  into  account  that  the 
patient  may  be  incurring  a  greater  danger  by  declining  it, 
besides  almost  complete  disability. 


CHAPTER  IX. 

MECHANICAL   TREATMENT   OF   INGUINAL   HERNIA   IN 
INFANCY   AND   CHILDHOOD. 

One-half  of  all  abdominal  hernias  occur  during  the  first 
five  years  of  life,  and  therefore  come  within  the  consideration 
of  this  branch  of  the  subject.  It  may  also  be  said  that  as 
regards  treatment  they  form  the  most  important,  but  by  no 
means  the  most  difficult  cases.  Important,  because  it  is  during 
this  period  that  the  defect  must  be  cured,  if  this  is  ever  to  be 
accomplished  without  an  operation.  It  is  also  important  in  the 
interest  of  the  infant's  good  health,  as  it  unquestionably  affects 
the  health  and  strength  of  the  infant  to  a  much  greater  extent 
than  it  does  an  adult. 

The  mechanical  treatment  of  inguinal  hernia  is  not  diffi- 
cult, and  there  are  very  few,  if  any,  surgical  affections  that 
should  be  so  thoroughly  under  the  control  of  the  family  physi- 
cian. Infants  are  easier  to  fit  than  the  adult,  and  they  will  be 
brought  to  the  physician  with  greater  regularity ;  there  is  free- 
dom from  many  complications  which  arise  later  in  life,  and 
they  prove  of  more  interest  because  they  are  cured  if  properly 
managed. 

Unfortunately,  however,  it  is  a  fact  that  children  are  grow- 
ing up  to  manhood  and  womanhood,  carrying  with  them  the 
liernise  of  infancy  because  of  lack  of  proper  attention  on  the 
part  of  the  family  physician.  The  case  has  been  brought  to 
the  doctor,  and  he  has  "  prescribed  "  a  truss,  and  recommended 
a  druggist  or  instrument  maker  who  deals  in  these  articles. 
Having  done  this,  he  feels  that  he  has  discharged  his  whole 
duty  to  his  patient,  and  gives  the  case  no  further  thought.  The 
dealer  sells  to  the  patient  whatever  truss  he  happens  to  be  inter- 
ested in,  or  has  in  stock,  the  case  itself  having  little  or  no 
influence  in  deciding  what  form  of  appliance  is  to  be  worn ; 
nor  in  the  majority  of  instances  is  the  instrument  selected  ever 

189 


190  ABDOMINAL  HERNIA. 

shaped  to  the  form  of  the  infant  who  is  to  wear  it.  In  fact, 
tlie  baby  is  fitted  to  the  truss  and  not  the  truss  to  the  baby.  The 
sale  of  the  truss  having  been  made,  no  one  but  the  parents  feel 
any  further  responsibihty  in  the  case,  and  this  rests  hghtly  with 
them  in  the  behef  that  just  the  right  thing  has  been  done.'  If, 
by  the  merest  chance,  the  truss  was  approximately  correct  at  the 
time  applied,  this  does  not  hold  true  a  few  weeks  later,  as  the 
child  is  rapidly  changing  in  shape  and  size.  The  parents  know 
nothing  of  the  advisability  of  frequently  refitting  the  truss,  the 
dealer's  interest  and  responsibility  terminated  with  its  sale,  the 
doctor  is  out  of  the  case  altogether  by  having  referred  to  the 
dealer,  and  the  result  is  the  child  goes  without  a  cure.  This  is 
all  wrong,  and  the  wrong  begins  with  the  family  physician  who 
first  sees  the  case  and  passes  it  into  unprofessional  hands.  He 
should  become  at  once  as  responsible  for  its  cure  as  he  would 
for  a  fractured  femur  or  a  dislocated  hip- joint.  If  he  cannot 
bring  to  bear  upon  it  better  knowledge  than  his  own,  then  it  is 
his  absolute  duty  to  do  the  best  he  can  himself. 

In  a  few  of  the  larger  cities  truss  makers  have,  by  practice, 
acquired  considerable  skill  in  fitting,  and  when  they  have  taken 
the  trouble  to  familiarize  themselves  with  the  anatomy  of  the 
parts,  and  have  no  special  hobby  or  patent  of  their  own  to 
exploit,  they  do  good  work ;  but  the  physician,  already  possess- 
ing the  knowledge  of  anatomy  and  methods  of  diagnosis,  will 
soon  obtain  by  experience  the  necessary  mechanical  skill,  and 
carry  out  treatment  in  a  far  more  scientific  manner  than  pos- 
sible for  an  unprofessional  man,  no  matter  how  honest  the 
intentions  of  the  latter  may  be.  He  would  also  find  that  not 
only  would  the  parents  fully  appreciate  his  efforts  in  behalf 
of  their  child,  but  by  the  cures  which  he  would  surely  obtain 
his  reputation  would  be  materially  enhanced. 

Fully  95  per  cent,  of  the  inguinal  herni?e  of  infancy  can 
be  cured  by  careful  mechanical  treatment,  but  this  must  not  be 
construed  to  mean  the  application  of  a  truss,  no  matter  how 
skillfully  done,  and  the  discharge  of  the  case.  It  means  taking 
the  case  under  care  and  observation  for  not  less  than  one  year, 


MECHANICAL  TREATMENT  :  INFANCY. 


191 


or  until  a  cure  is  effected.  It  is  important  to  discover,  when 
possible,  the  cause  of  the  hernia  in  the  infant.  Of  course,  if 
due  to  congenital  defect,  time  alone  can  remove  it,  but  it  will 
surprise  a  good  many  physicians  to  know  how  often  the  cause 
can  be  ascertained  and  removed.  In  this  connection,  I  will 
again  call  attention  to  the  frequency  of  hernia  resulting  from 
constipation,  whooping-cough,  tight  belly-bands,  and  long- 
continued  crying.  Attention  to,  and,  so  far  as  possible,  removal 


Five  weeks  old  boy  with  right  complete  inguinal  hernia  and  hydrocele  of  tunica  vaginalis  on 
the  same  side.    Hard-rubber  cross-body  truss  applied. 

of,  these  causes  is  the  first  essential  of  successful  treatment. 
This  branch  of  the  subject  has  already  been  considered  under 
the  cause  and  diagnosis  of  hernia. 

The  mechanical  treatment  of  hernia  in  infancy  is  believed 
to  be  the  better  method,  for  the  reason  that  many  can  carry  it 
out  who  are  not  qualified  to  do  a  surgical  operation,  and  that 
the  final  result  is  equally  good.  The  general  practitioner  can.  if 
willing  to  devote  the  necessary  time,  secure  good  results  with- 
out the  use  of  the  knife.  There  are  very  few  ruptured 
infants  that  cannot  be  cured  by  the  family  physician.      State- 


192 


ABDOMINAL  HERNIA. 


ments  that  operations  are  advisable  on  children  because  trusses 
cannot  be  worn,  are  born  of  absolute  ignorance  of  the  me- 
chanical treatment  of  hernia;  as  a  matter  of  fact,  infants 
tolerate  truss  pressure  better,  if  that  pressure  is  intelligently 
applied,  than  do  adults.  It  is  unfortunate  that  almost  all  infant 
trusses  are  made  entirely  too  strong,  and  if  applied  as  sent  out 


Fig.  94. 


Hood  truss  applied  to  child  six  months  old. 

from  the  factory,  must  cause  pain,  if  not  actual  injury,  to  the 
delicate  tissues.  It  is  just  here  that  the  physician's  knowledge 
and  supervision  is  essential.  Nor  is  it  a  fact  that  hernia  cured 
by  truss  is  more  liable  to  recur  tlian  wlien  the  same  result  has 
been  brought  about  by  an  operation.  It  has  been  a  matter  of 
surprise  that  so  few  of  the  many  children  who  have  been  under 
personal  care  and  cured  during  the  past  twenty-five  years  have 


MECHANICAL  TREATMENT:  INFANCY. 


193 


had  a  return  of  tlieir  ruptures.  The  recurrences  have  been 
wholly  due  to  some  violence,  as  whooping-cough,  bronchitis,  or 
some  other  cause,  which  would  have  been  quite  as  likely  to  have 
produced  hernia  in  a  child  who  had  never  had  it. 

The  age  at  which  mechanical  treatment  may  be  begun  is 
a  question  which  many  physicians  are  in  doubt  about,  and  one 
often  asked  in  the  lecture-room ;  the  answer  being  that  an 
infant  old  enough  to  be  the  possessor  of  a  hernia  is  quite  old 
enough  to  have  the  hernia  treated    (figs.   93,   94,   and  95). 

Fig.  95. 


Cross-body  hard-rubber  truss  as  usually  applied  without  perineal  uuder-strap. 


Trusses  have  repeatedly  been  put  on  babies  ten  days  and  two 
weeks  old,  and  there  has  been  no  occasion  to  regret  beginning 
treatment  at  this  early  date.  It  is  an  erroneous  idea,  and 
unfortunately  a  rather  prevalent  one,  even  with  physicians,  that 
a  baby  wall  **  outgrow  ''  this  defect,  or  that  it  is  "  better  to  delay 
treatment  until  the  child  is  older."  It  being  conceded  that  it  is 
advisable  to  begin  treatment  as  soon  after  the  development  of 
the  hernia  as  possible,  the  next  question  is  as  to  the  manner  of 
supporting  the  protruding  viscera.  There  is  no  bandage  or 
makeshift  of  any  description  that  will  take  the  place,  either  for 

13 


194 


ABDOMINAL  HERNIA. 


comfort,  cleanliness,  or  efficiency,  of  a  carefully  applied  truss 
containing  a  metallic  spring,  and  covered  by  material 
impennous  to  moisture,  such  as  hard  rubber  or  celluloid. 
Elastic  bands,  so-called  elastic  trusses,  and  bandages  such  as  a 
"hank"  of  worsted  (fig.  96)  have  been  recommended  at 
various  times ;  but  they  are  a  delusion  and  a  snare,  and  usually 
an  abomination. 

There  is  no  lack  of  good  trusses  in  this  country.  The 
druggists  of  every  town  and  hamlet  in  the  United  States  are 
annually  visited  by  representatives  of  manufacturers,  whose 


Fig  96. 


Application  of  a  skein-of-wool  truss.     (Eccles  )    This  is  considered  a  very  poor  makeshift. 

products  are  not  equalled  in  any  other  part  of  the  world,  and 
still  the  number  that  are  really  suited  for  use  on  infants  is  very 
small,  owing  either  to  defects  in  the  original  design  of  the 
truss,  or  because  of  their  being  entirely  too  strong,  even  where 
the  form  of  the  truss  is  correct.  All  infant  trusses  which  are 
made  to  apply  from  the  side  of  the  rupture,  all  of  those  where 
the  pad  is  placed  upon  a  descending  arm  at  a  level  lower  than 
the  pelvic  spring,  and  all  trusses  cushioned  or  padded  with 
soft  material,  are  condemned.  The  so-called  French  and  Ger- 
man style  of  trusses,  which  comprise  tlie  bulk  of  stock  of  many 
druggists,  should  have  become  obsolete  a  half-century  ago. 


MECHANICAl.  TREATMENT:  INFANCY.         195 

In  truss  selection  the  following  points  sIkjuUI  Ijc  remem- 
bered :  ( I )  The  spring-  should  be  so  tempered,  if  steel,  that  it 
may  be  readily  bent  to  the  shape  of  the  child,  and  its  pressure 
added  to  or  diminished  by  increasing  or  removing  the  amount 
of  curve  which  it  possesses.  (2)  The  entire  truss  should  be 
water-proof,  that  it  may  be  frequently  w^ashed  and  not  damaged 
by  urine.  Any  material  which  absorbs,  and  holds  in  con- 
tact with  the  child's  skin,  its  excretions,  will  cause  scalding  and 

Fig.  97. 


Left  complete  inguinal  hernia  in  child  S  years  old,  retained  by  hard-rubber  cross-body 
truss  with  perineal  under-strap.     The  latter  is  seldom  required. 

excoriation,  besides  being  actually  filthy.  (3)  The  truss 
should  be  simple  and  durable.  The  more  simple  in  design  the 
better  is  the  truss,  as  a  rule.  Pads  with  ball-and-socket  self- 
adjusting  action,  so-called,  or  with  complicated  set  screws  for 
adjustment,  are  entirely  unnecessary  and  soon  become  useless. 
For  the  treatment  of  single  inguinal  hernia,  in  the  infant, 
the  cross-body  spring,  which,  from  the  pad,  crosses  the  front 
of  the  abdomen,  passes  around  the  hip  of  the  opposite  side,  and 
across  the  back,  is  one  of  the  most  valuable  appliances  that 
can  be  used    (figs.  93,  97).     This  truss  can  be  obtained  of 


196 


ABDOMINAL  HERNIA. 


almost  every  druggist  in  the  country,  the  spring  is  covered 
either  with  hard  rubber  or  cehuloid  and  known  in  the  trade 
as  the  "  cross-body  "  truss.  A  spring  of  this  kind  will  sur- 
round about  two-thirds  of  the  pelvis,  and  while  it  is  supplied 
with  a  strap  to  complete  the  circumference,  it  readily  holds  itself 
in  place  whether  the  strap  is  used  or  not.  Its  pressure  can 
readily  be  adjusted  to  the  requirements  of  the  case  by  increasing 
or  diminishing  the  curve  of  the  spring.  Those  covered  with 
celluloid  have  the  advantage  of  being  readily  shaped  to  the 

Fig.  q8. 


De  Garmo-Hood  truss,  German  silver  spring,  hard-rubber    cover.      Applied  to  small  right 
oblique  inguinal  hernia. 

form  without  heating  ( which  is  necessary  in  shaping  the  hard- 
rubber  springs),  but  have  the  disadvantage  of  being  not  quite 
so  durable  as  those  with  the  hard-rubber  covering. 

The  "  Hood  "  truss,  covered  by  celluloid  or  hard  rubber, 
is  made  in  infant  sizes  and  kept  by  most  dealers,  and  forms  an 
extremely  desirable  truss  for  children  whose  pelvic  measure 
exceeds  sixteen  inches,  but  is  not  desirable  in  those  of  smaller 
size. 

The  De  Garmo-Hood  truss  (fig.  98,  99)  differs  from  the 
others  in  having  a  spring  of  German  silver  instead  of  steel,  the 


MECHANICAL  TREATMENT:  INFANCY. 


197 


covering  being  of  hard  rubber.  This  material  for  springs  in 
this  form  of  truss  has  proven  very  valuable,  owing  to  its  being 
readily  shaped  to  form  without  liability  of  breaking,  and 
because  of  its  not  having  the  action  of  compression  found  in 
the  steel  spring.  This  truss  has  been  extensively  used  in  my 
private  work.  Manufacturers  have  told  me  that  they  could 
not  sell  it  to  the  dealers  because  it  was  considered  too  lig'ht,  and 
this  clearly  indicates  how  little  the  dealers  comprehend  the 
recjuirements  of  a  proper  truss  for  infants. 

Fig.  99. 


Right  complete  oblique  hernia  in  boy  of  S  years.     Retained  by  De  Garmo-Hood  truss. 

The  measure  for  selecting  the  size  of  the  truss  should  begin 
just  above  where  the  hernia  is  seen;  that  is,  at  the  internal 
abdominal  ring,  passing  around  the  hips  midway  between  the 
crest  of  the  ilium  and  the  trochanter  major.  This,  in  number 
of  inches,  will  indicate  the  size  of  the  truss  required.  In  the 
shaping  of  the  spring,  the  diagram  method,  previously  de- 
scribed, will  be  found  of  the  greatest  service.  The  diagram  is 
used  instead  of  the  child.  If  a  spring  covered  with  hard  rubber 
is  used,  it  should  be  passed  through  the  flame  of  a  spirit  lamp 
until  it  is  quite  warm,  and  it  can  then  be  bent  to  the  exact  shape 


198 


ABDOMINAL  HERNIA, 


required.  As  before  stated,  and  it  cannot  be  repeated  too 
often,  most  infant  trusses,  as  sent  out  from  the  shops,  are  too 
strong  in  pressure,  and  this  should  be  carefully  guarded  against. 
Only  a  light  pressure  is  required  if  the  location  of  the  pad  is  at 
the  right  spot.  A  very  common,  almost  universal,  error,  in 
applying  trusses,  especially  to  infants,  is  in  putting  the  pad  too 
low  (fig.  lOo).  If  the  pad  rests  on  the  pubic  bone  its  efficiency 
is  at  once  destroyed  and  the  discomfort  of  the  child  is  assured. 

Fig.   ioo. 


Boy  of  12  years  wearing  the  German  type  truss.  Fitting  on  right  side  good,  on  left  bad, 
owing  to  the  use  of  what  the  truss  makers  call  a  scrotal  hernia  pad.  In  this  case,  omentum 
was  adherent  in  scrotum. 


It  should  be  borne  in  mind  that  the  design  of  truss-wearing  is 
to  keep  the  bowel  entirely  within  the  abdomen,  and  in  order  to 
accomplish  this  perfectly,  the  supporting  pressure  must  be  very 
nearly  over  the  internal  ring.  The  descent  of  the  hernia, 
stopped  at  the  external  ring,  may  in  this  way  be  kept  out  of 
sight,  but  still  occupies  the  upper  part  of  the  canal,  and  a  cure 
will  never  result.  A  truss  pad  that  rests  against  the  bone 
cannot  thoroughly  protect  the  upper  part  of  the  canal.  It  is 
held   away   from   it,    and   the   child   is   made   uncomfortable. 


MECHANICAL  TREATMENT:  INFANCY.         199 

When  the  truss  is  fitted  high  the  parts  Ijack  of  the  pad  are 
soft  and  yielding,  and  discomfort  is  not  caused. 

Having  fitted  the  truss,  the  care  of  the  case  has  only  just 
begun.  The  case  must  be  kept  under  observation  and  the 
truss  changed  in  shape  and  size  as  the  child  grows.  This 
change  and  growth  is  very  rapid,  and  the  child  should  at  first 
be  seen  at  least  once  a  week,  and  not  allowed  to  pass  entirely 
from  care  nntil  it  is  cured.  In  case  of  whooping-cough  or 
severe  bronchitis  supervening,  it  is  advisable  to  increase  the 
truss  pressure  temporarily,  but  otherwise,  after  the  first  three 
months,  it  is  well,  if  the  hernia  does  not  protrude,  to  begin  to 
reduce  the  pressure.  One  year  is  the  shortest  period  that  a 
truss  should  be  worn,  and  it  should  never  be  removed  by  the 
mother  except  for  purposes  of  cleanliness,  and  this  should  be 
while  the  child  is  in  a  quiet  and  recumbent  position.  Absolute 
cleanliness  must  be  insisted  upon,  and  if  the  skin  is  kept  clean 
and  dry,  it  will  tolerate  strong  truss  pressure  without  abrasion. 
The  free  use  of  a  good  talcum  toilet-powder  is  quite  essential 
to  the  comfort  of  the  infant  truss  wearer.  After  the  careful 
cleaning  and  drying  of  the  parts,  it  should  be  freely  applied  to 
the  skin  before  placing  the  pad.  Several  good  powders  are  on 
the  market,  or  the  formula  given  under  general  instructions, 
which  was  devised  for  this  purpose  many  years  ago  and  which 
has  stood  the  test  of  time,  may  be  used.  Where  an  abrasion 
has  once  occurred  and  is  slow  to  heal,  on  account  of  constant 
wetting  by  urine  and  the  irritation  of  the  truss,  I  have  found 
nothing  better  than  balsam  of  Peru. 

As  previously  stated,  the  truss  should  be  kept  on  for  a 
period  of  one  year;  if,  however,  the  case  has  been  one  of  con- 
genital hernia,  it  is  best  to  prolong  the  wearing  for  two  years. 
The  truss  pressure  should  be  gradually  lightened,  until,  dur- 
ing the  last  six  months,  it  serves  merely  as  a  protective  sup- 
port against  the  recurrence  of  the  hernia.  If  a  strong  truss 
were  worn  during  the  same  length  of  time  and  then  entirely 
removed,  there  would  be  a  far  greater  liability  of  the  return  of 
the  trouble.     Attention  to  the  child's  general  condition  should 


200  ABDOMINAL  HERNIA. 

not  be  overlooked.  Constipation  must  be  prevented  and  the 
digestive  apparatus  looked  after.  It  adds  greatly  to  the  diffi- 
culties of  controlling  hernia  if  the  intra-abdominal  pressure  is 
mcreased  by  flatulent  distention  of  the  intestines. 

Among  the  complications  mentioned,  fluid  in  the  tunica 
vaginalis  is,  perhaps,  the  most  common  and  certainl}'  the  most 
perplexing.  This  fluid,  which  is  usually  reducible  to  the 
abdominal  cavity  through  the  neck  of  the  tunica,  may  be  present 
when  the  case  first  comes  under  observation,  but  more  fre- 
quently forms  during  treatment.  It  occurs  in  many  cases  of 
congenital  hernia,  usually  from  one  to  two  months  after 
treatment  has  begun.  The  parent  will  bring  the  child  back  and 
tell  you  that  the  rupture  is  not  as  completely  held  by  the  truss 
as  it  formerly  was,  and  that  it  is  down  almost  all  the  time. 
The  means  of  distinguishing  this  from  the  hernia  have  already 
been  mentioned. 

As  regards  treatment,  it  is  best  to  let  the  fluid  alone  except 
in  some  rare  instances  where  its  quantity  is  so  great  as  to 
inconvenience  the  child.  If  it  ceases  to  return  to  the  abdomen, 
indicating  that  the  communicating  neck  has  been  obliterated, 
forming  true  hydrocele,  it  is  well  enough  to  tap  with  a  small 
trocar,  and  this  is  usually  sufficient  to  produce  a  complete  cure. 
If  from  any  cause  the  child  has  an  effusion  of  fluid  within  the 
abdominal  cavity  and  hernia,  the  fluid  will  also  fill  the  hernial 
sac.  In  cases  of  this  character  truss  pressure  should  be  con- 
tinued in  order  to  protect  the  tissues  about  the  canal.  The 
fluid  cannot  be  retained  by  any  form  of  truss. 

Non-descent  of  the  testicle,  associated,  as  it  usually  is,  with 
hernia,  requires  careful  consideration.  We  should  never  fail 
to  examine  carefully  the  scrotum  of  the  ruptured  child.  It  is 
not  uncommon  to  see  boys  of  eight  and  ten  years  old  in  whom 
it  has  never  been  discovered  that  only  one  testicle  was  present 
in  the  scrotum.  In  infancy  this  defect  is  likely  to  be  over- 
looked, or,  what  is  worse,  if  the  testicle  lies  just  outside  the 
external  ring  it  is  mistaken  for  hernia,  reduced,  and  kept  back 
bv  a  truss.     When  the  testicle  is  in  the  canal,  treatment  will. 


MFXHANICAL  TREATMENT:  INFANCY.         ;^01 

in  many  instances,  have  to  be  delayed  until  it  passes  the  external 
ring;  then  a  small  pad  may  be  applied  over  the  upper  part  of 
the  canal. 

In  giving  mechanical  means  the  first  place  in  the  treatment 
of  hernia  in  infancy,  I  do  not  wish  to  Ije  understood  as  disap- 
proving surgical  measures.  On  the  contrary,  I  believe  that  it 
is  as  justifiable  to  operate  for  the  cure  of  hernia  in  a  child  as  it 
is  for  the  cure  of  clubfoot  or  other  malformations.  If  by 
mechanical  means  we  cannot  correct  either,  it  is  our  duty  to 
operate.  In  clubfoot  there  are  cases  which  an  experienced 
orthopedic  surgeon  could  confidently  state  would  never  be 
cured  by  mechanical  appliances,  but  this  is  scarcely  ever  true 
of  hernia,  some  of  the  most  extreme  cases  in  infancy  yield- 
ing promptly  and  a  permanent  cure  resulting  without  the 
use  of  the  knife.  Tliis  being  true,  beyond  all  question  it  is 
our  duty  to  try  the  mild  means  first.  If  this  is  faithfully 
carried  out,  it  will  be  found  that  few  cases  remain  requiring 
operation. 

CARE    OF    SKIN    AND    GENERAL    INSTRUCTIONS 
TO   TRUSS  WEARER. 

It  is  a  matter  of  the  utmost  importance  that  the  truss- 
wearer  be  instructed  how  to  care  for  the  surface  of  the  skin 
under  the  bearing  of  the  truss  pad,  as  it  will  save  him  much  dis- 
comfort. He  must  also  be  taught  how  to  put  on  and  take  off 
his  truss  and  cautioned  regarding  the  danger  incurred  by  going 
about  without  it,  even  while  in  his  own  room.  It  is  best  that 
he  should  also  know  how  to  reduce  his  own  hernia  and  how  to 
act  in  case  he  finds  this  impossible.  The  fatality  attending 
strangulated  hernia  is  in  many  instances  due  to  the  ignorance 
of  the  patient  regarding  its  dang'ers.  The  first  essential  to 
comfortable  truss-wearing  is  that  the  skin  pressed  upon  l^y  the 
pads  shall  be  kept  strictly  clean  and  dry.  Not  only  must  the 
skin  be  kept  clean,  but  the  truss  itself  must  be  frequently 
washed.  Besides  the  keeping  of  the  parts  clean,  it  has  been 
found  desirable  to  bathe  the  skin  frequently  with  equal  parts  of 


202  ABDOMINAL  HERNIA. 

alcohol  and  fluidextract  of  hamamelis  leaves;  following  this, 
after  drying,  by  the  application  of  a  good,  mildly  antiseptic 
powder.  The  author  has  found  nothing  superior  in  the  way  of 
a  powder  to  that  published  by  him  many  years  ago,  which  was 
designed  for  this  special  use,  and  the  formula  of  which  is  here 
given : 

R     Amyli  ^iv 

Cretse  Gallicae  (powdered  French  ghalk)  §ii 

Alum,  ust., 

Acidi  boracic,  aa  3  ii 

Acidi  carbolic!, 

01.  limonis,  aa  ^ss 

M.  Sig. — Powder  very  fine. 

It  should  be  made  into  a  very  fine  powder  and  used  by 
dusting  the  parts  freely  beneath  the  truss  pad.  As  a  toilet 
powder,  for  general  use  on  infants,  this  will  also  be  found 
superior  to  those  commonly  on  the  market. 

If  the  skin  has  been  broken,  or  suppuration  has  occurred 
beneath  the  truss  pad,  as  it  sometimes  will,  balsam  of  Peru 
has  been  found  useful.  In  slight  excoriations  the  use  of  ben- 
zoated  oxide  of  zinc  ointment  heals  the  surface  quickly.  Its 
action  is  especially  good,  on  infants,  where  the  skin  lesion  is 
started  by  urine  getting  beneath  the  truss  pad.  If  there  is 
suppuration,  the  pus  should  be  washed  off  thoroughly  with  a 
solution  of  hydrogen  dioxide  and  the  Peruvian  balsam  freely 
applied.  Healing  may  frequently  be  accomplished  in  this  way 
without  confinement  to  bed  or  the  discontinuance  of  the  use 
of  the  truss. 

There  should  be  no  compromise  with  a  patient  who  suffers 
from  a  well-developed  hernia,  on  the  necessity  of  continuous 
truss-wearing.  If  for  any  reason  he  is  obliged  to  discontinue 
its  use  temporarily,  safety  demands  that  he  should  maintain  the 
recumbent  position  until  such  time  as  he  can  resume  his  truss. 
The  man  who  has  retained  his  hernia  by  a  truss,  for  a  time,  and 
then  discontinues  its  use,  is  in  greater  danger  of  strangulated 
hernia  than  lie  who  lias  never  worn  one. 


MECHANICAL  TREATMENT:  INFANCY.         203 

Trusses  worn  by  adults  should  be  removed  at  night  after 
the  patient  is  in  bed,  being  reapplied  in  the  morning  before 
getting  up.  If  the  patient  has  a  persistent  cough,  or  the  hernia 
is  so  large  that  protrusion  occurs  while  lying  down,  then  a 
special  night  truss  should  be  provided.  The  elastic  truss  is 
best  suited  for  this  use.  He  should  understand  that  the  truss 
suitable  for  night  use  is  worthless,  even  dangerous,  for  day 
use,  and  that  a  truss  suited  for  day  is  unfit  for  use  at  night. 
Also  that,  in  a  measure,  he  is  disabled  for  life,  or  until  cured, 
and  that  he  must  remain  under  the  observation  of  his  physi- 
cian. A  properly  selected  and  good-fitting  truss  restores  him, 
for  the  time  being,  to  normal  condition.  Owing,  however,  to 
changes  in  his  shape,  changes  in  the  truss,  or  bad  habits 
formed  in  the  wearing  of  a  good  truss,  he  should,  for  safety, 
submit  himself  to  frecjuent  inspection. 

A  convenient  way  to  instruct  my  patients  has  been  to  hand 
them  a  printed  slip  containing  the  following : 

INSTRUCTIONS     TO     TRUSS-WEARERS. 

Apply  your  truss  before  rising  in  the  morning. 

Before  applying,  be  sure  that  none  of  the  hernia  is  protruding. 

Remove  the  truss  after  getting  in  bed  at  night ;  if  correctly 
fitted,    it   will   need   no   attending   during  the   day. 

In  extreme  cases  a  night  truss  may  be  needed.  The  one 
provided  for  day  wear  is  unfit  for  such  use. 

Infants  and  young  children  should  wear  the  truss  both  night 
and  day. 

Never   go   about   your   room   without   truss   on. 

In  taking  shower  bath  keep  truss  on. 

Wash   the    truss — water   will    not   harm   it. 

Extreme    cleanliness    will    add    to   comfort. 

Bathing  the  skin  at  night  with  equal  parts  of  alcohol  and 
Pond's  extract  will  reduce  irritation. 

The  free  use  of  a  good  talcum  powder  in  the  morning  is 
advised. 

It  is  not  safe  to  wear  the  truss  over  your  underwear. 

Any  unusual  abdominal  pain  or  discomfort  should  lead  you 
to  examine  your  hernia.  If  protruding,  it  should  be  at  once 
replaced  and  the  truss  readjusted.  This  should  be  done  while 
lying  down  if  possible.  If  replacement  of  hernia  is  impossible 
and  pain  is  severe,  apply  an  ice  bag  and  send  for  physician. 
Delay   is  dangerous. 


CHAPTER  X. 

TREATMENT  OF  INGUINAL  HERNIA  BY 
GYMNASTICS. 

Works  relating  to  abdominal  hernia  seldom  mention 
gymnastics  as  an  aid  to  palliative  or  curative  treatment.  It  is, 
however,  deemed  quite  worthy  of  consideration,  and  there  is 
evidence  both  for  and  against  it. 

On  one  hand,  a  large  number  of  patients  have  been  seen 
who  have  developed  hernia  by  misguided  physical  exercise  or 
who,  already  having  hernia,  have  forced  it  down  to  such  an  ex- 
tent that  strangulation  or  incarceration  has  occurred.  On  the 
other  hand,  many  cases  have  been  seen  who  have  received  de- 
cided improvement  from  its  use.  I  cannot  say,  however,  that  of 
my  own  personal  knowledge  I  know  of  any  hernise  permanently 
cured.  I  do  not  wish  to  intimate  that  I  doubt  the  statement 
of  scientific  and  careful  observers  who  make  contrary  state- 
ments. Naturally  those  cases  only  who  have  hernia  apply  for 
relief,  and  those  who  have  been  cured  have  no  occasion  to. 
There  is  no  doubt  that  the  development  of  the  muscles  of  the 
lower  abdomen  aids  materially  in  the  retention  of  hernia,  even 
to  the  extent  of  its  complete  retention  for  a  time  in  some 
instances,  and  I  have  for  many  years  advised  parents  to  allow 
their  sons  to  go  into  almost  any  physical  sport  that  they  choose 
football  excepted, ,  provided  they  were  wearing  a  truss  that 
retained  their  herniae.  In  very  early  youth  I  am  convinced 
that  increased  muscular  tone  aids  in  obtaining  a  cure  without 
operation. 

Furthermore,  we  must  not  pass  by  without  due  considera- 
tion the  experience  of  such  an  able  scientific  observer  as  Jay  W. 
Seaver,  A.M.,  M.D.,  who  for  many  years  has  had  charge  of  the 
physical  education  of  the  students  at  Yale  College.  He  has 
tabulated  the  physical   examinations   of  over  35,000  college 

204 


TREATMENT  BY  GYMNASTICS. 


205 


students.  Among-  this  number  he  found  nearly  3  per  cent,  of 
the  young  men  had  inguinal  hernia  (The  Treatment  of 
Inguinal  Hernia  in  the  Young,  Yale  Medical  Journal,  Feb., 
1900,  and  Feb.,  1904).  Believing  that  those  young  men  who 
had  hernia,  represented  a  type  that  especially  needed  physical 
development,  he  made  it  a  rule  not  to  excuse  them  from  gym- 
nastic exercises,  unless  especially  recjuested  to  do  so  by  the 
family  physician.  He  directs  that  a  suitable  truss  be  applied 
and  after  the  patient  has  become  accustomed  to  it,  the  following 
exercises  be  taken  twice  daily,  the  severity  of  the  movements 
being  gradually  increased : 

Fig.  ioi. 


"(i)  Lying  on  the  back  with  thin  cushion  under  head, 
raise  the  right  knee,  drawing  it  as  close  to  the  chest  as  possible, 
making  special  effort  in  the  last  part  of  the  movement.  Then 
extend  the  leg  and  perform  the  same  movement  with  the  left. 
Repeat  the  movement  five  times  with  each  leg,  then  raise  both 
knees  toward  the  chest,  doubling  far  enough  to  raise  the  j^elvis 
from  the  floor,  placing  the  hands,  palms  down,  just  under  the 
hips ;  repeat  five  to  ten  times.  It  will  be  found  much  easier  to 
take  these  exercises  lying  on  a  rug  than  on  a  bed,  as  a  solid 
support  gives  the  necessary  resistance  for  the  movement 
(figs.  IOI,  102). 


206 


ABDOMINAL  HERNIA. 


"  (2)    Lying  on  back  with  thin  pillow  under  head  and 
hands  under  back  of  neck,  draw  feet  up  to  buttocks,  then  raise 


Fig.  102 


hips  from  floor  as  far  as  possible  bearing-  the  weight  on  the  feet 
and  shoulders.  Repeat  this  exercise  ten  times.  This  movement 
will  tend  to  strengthen  the  muscles  of  the  abdomen  and  loins, 

Fig.  103. 


and  is  not  a  specially  severe  movement.     This  movement  will 
be  of  increased  value  if  the  person  will  inhale  deeply  while  hold- 


TREATMENT  BY  GYMNASTICS. 


^207 


ing  the  pelvis  from  the  floor  and  exhale  as  the  body  is  lowered 
(%  103). 

■*  (3)  From  horizontal  position  on  Ijack,  raise  right  leg  to 
perpendicular,  keeping  the  knee  as  straight  as  possible,  and 
keeping  left  leg  straight  on  floor,  and  hands  with  palms  down, 
just  under  the  hips.  Repeat  five  times.  Take  the  same  exer- 
cise with  left  leg;  then  raise  both  legs  to  the  perpendicular 
position  an  equal  number  of  times,  remembering  to  keep  the 
leg  straight  at  the  knee.  The  movement  may  also  be  taken 
with  fingers  back  of  neck,  but  is  more  difficult.     This  is  a 

Fig.  104. 


strong  movement  and  must  not  be  repeated  so  many  times  as  to 
produce  serious  soreness  of  the  abdominal  muscles.  By 
increasing  at  the  rate  of  one  movement  every  second  dav.  a 
healthy  person  may  expect  to  accomplish  twenty  repetitions 
without  discomfort  (fig.  104). 

"  (4)  Lying  on  back,  spread  the  legs  so  that  the  feet  are 
three  feet  apart,  then  roll  on  to  left  shoulder,  touching  the 
floor  with  the  right  fingers  as  far  as  possible  beyond  the  left 
shoulder,  keeping  the  hips  squarely  upon  the  floor  during  the 
entire  movement.  Repeat  five  times  and  then  take  the  same 
exercise,  twisting  the  trunk  to  the  right  (figs.  105  and  106). 


208  ABDOMINAL  HERNU. 

"  (5)  Lying  horizontal  on  back,  with  fingers  back  of  neck, 
raise  right  leg  and  touch  on  floor  as  near  the  left  shoulder  as 


Fig.  105. 


possible,  keeping  the  shoulders  scjuare  upon  the  floor.     Repeat 
five  times  and  take  the  same  exercise  with  the  left  leg.     This 

Fig.  106. 


movement   is  of   special   value   in   strengthening   the  oblique 
muscles  of  the  abdomen  (fig.  107). 


TREATMENT  BY  GYMNASTICS. 


209 


"  (6)  Standing  in  erect  position,  with  the  head  and  hips 
well  back,  inhale  deeply,  and,  at  the  same  time,  draw  in  the 
lower  abdomen  as  much  as  possible.  Then  relax  the  abdominal 
wall  and  exhale.  Repeat  from  five  to  ten  times,  always  trying 
to  contract  the  lower  part  of  the  abdomen  and,  so  far  as  pos- 
sible, push  out  the  upper  part  near  the  waist  line.  Then  reverse 
this  movement  by  contracting  the  waist  line  \'igorously  and 
cause,  as  nearly  as  possible,  the  wave  of  contraction  to  pass 
down  over  the  abdominal  wall. 

Fig.  107. 


"  (7)  Standing  in  position,  with  weight  on  the  balls  of  the 
feet,  with  head  and  hips  well  back,  raise  the  arms  forward  and 
upward,  keeping  the  fingers  well  extended  and  palms  parallel 
until,  at  the  perpendicular  position,  they  are  the  same  distance 
apart  as  the  breadth  of  shoulders.  Inhale  as  the  arms  move 
upward,  and  use  at  least  ten  seconds  in  this  inhalation.  Then 
allow  the  arms  to  sweep  downward  to  the  original  position,  and 
the  air  to  escape  by  the  nose.     Repeat  six  to  ten  times. 

"  (8)  Standing  erect,  with  head  well  back,  raise  the  hands 
sideward  and  upward  to  the  horizontal  position.  Then  bend 
the  arms  at  the  elbows  until  the  finger  tips  toucli  those  of  the 
opposite  hand  on  the  back  of  the  neck.     Then  inhale  deeply. 

14 


210 


ABDOMINAL  HERNL\. 


pushing  the  elbows  upward  and  backward  as  far  as  possible. 
keeping  wrists  firm,  and  then  exhale  as  the  elbows  are  lowered, 
move  slightly  forward,  but  retain  the  finger  tips  in  position  on 
the  back  of  the  neck,  and  the  neck  well  back  during  both 
inspiration  and  expiration.  Repeat  five  to  ten  times.  The 
abdominal  wall  must  be  made  to  move  freely  in  this  exercise, 
and  it  will  be  found  that  no  free  movement  of  respiration  can 
be  accomplished  in  this  position,  except  by  a  use  of  the 
diaphragm  and  general  abdominal  wall. 

Fig.  ioS. 


(9)  Lying  in  a  horizontal  position  with  the  toes  under  a 
sofa  or  any  suitable  piece  of  furniture,  raise  to  a  sitting 
posture,  keeping  the  neck  well  back  during  the  entire  move- 
ment. There  will  be  a  decided  tendency  while  taking  this 
exercise  to  throw  the  head  forward  and  bow  the  back.  This 
must  not  be  done.  This  exercise  ma}-  be  repeated  from  three 
to  ten  times  according  to  the  strength  of  the  individual  (fig. 
108). 

(10)  Lying  on  the  stomach,  extend  the  toes  on  the  floor 
and  the  arms  in  the  opposite  direction  so  as  to  secure  the  great- 
est length  possible  from  tip  of  toes  to  tip  of  fingers.  Then. 
with  feet  raised  as  far  from  the  floor  as  possible,  inhale  deeply 


TREATMENT  BY  GYMNASTICS.  211 

for  at  least  ten  seconds.  Then  exhale  slowly,  using  about  one- 
half  this  time  in  returning-  to  the  quiescent  condition.  Repeat 
from  three  to  five  times,  keeping  the  muscles  of  the  limbs  tense 
as  in  stretching  during  inhalation." 

Dr.  Seaver  advocates  the  use  of  the  flattest  truss  pad  that 
will  retain  the  hernia  and  the  gradual  removal  of  pressure  as 
the  case  improves.  He  believes  that  75  per  cent,  of  herniae 
occurring  in  young"  men  under  twenty-five  years  of  age,  could 
be  cured  by  the  means  suggested,  and  concludes  as  follows  : 

"  First,  I  w^ould  recommend  a  surgical  operation  as  the 
quickest  and  more  efficient  treatment  for  severe  or  long-con- 
tinued cases  of  inguinal  hernia,  where  the  matter  of  expense 
need  not  be  considered,  and  wdiere  there  is  no  serious  mental 
antipathy  to  an  operation.  Second,  I  would  recommend  what 
may  be  properly  called  the  g}annastic  treatment  of  such  cases 
as  are  recent  in  development,  and  where  the  inguinal  ring  is 
not  unduly  dilated,  although  the  case  may  be  of  fairly  long 
standing;  also  in  all  cases,  however  severe,  where  surgical 
operation  is  not  possible.  Third,  I  consider  the  mere  applica- 
tion of  a  truss,  however  good  it  may  1d€  and  whatever  the  price 
paid  for  it,  as  simply  palliative  treatment." 

Geo.  H.  Taylor,  M.D.,  published  a  work  in  1885  (John  B. 
Alden,  New  York)  on  "  Pelvic  and  Hernial  Therapeutics," 
including  "  Process  for  Self-Cure."  While  this  work  contains 
many  valuable  suggestions,  it  has  been  productive  of  much 
harm  in  that  it  leaves  the  patient  with  the  impression  that  he  is 
fully  qualified  to  carry  out  his  own  cure.  I  have,  in  speaking 
of  the  causes  of  hernia,  already  stated  my  experience  with  the 
"  Correspondence  Schools  of  Physical  Culture,"  and  must 
again  condemn  any  form  of  gymnastic  exercise,  for  ruptured 
people,  that  is  not  personally  supervised  by  an  experienced 
instructor  who  appreciates  its  dangers  as  well  as  its  good  parts. 
A  small, but  more  recent  work  by  Bernard AlacFadden  ("Natu- 
ral Cure  for  Rupture,"  Physical  Culture  Publishing  Co..  New 
York,  1902),  gives  a  series  of  exercises  which  he  terms  first, 
second,  and  third  system,  showing  a  gradual  but  an  extremely 


212  ABDOMINAL  HERNIA. 

trying  exercise  for  the  abdominal  muscles,  which  should  never 
be  used  except  under  personal  supervision. 

It  is  believed,  as  claimed  by  Dr.  Seaver,  that,  for  young 
people,  systematic  and  carefully  supervised  gymnastic  exercise 
is  an  important  aid  in  the  non-operative  cure  of  inguinal 
hernia,  but  it  is  also  considered  a  dangerous  method  for  people 
nearing,  or  past,  middle  life. 

CURE  OF  HERNIA  BY  INJECTION. 

This  method  of  treatment  would  receive  no  mention  in 
this  work  if  it  had  not  been  so  extensively  brought  before  the 
profession  and  so  strongly  endorsed  (principally  by  those  hav- 
ing a  monetar)"  interest  in  it)  as  to  deceive  those  not  familiar 
with  the  subject.  From  the  fact  that  its  use  is  almost  always 
temporarily  beneficial,  and  that  it  is  curative  in  a  few  (very 
few)  cases,  it  is  not  surprising  that  many  physicians  should  be 
misled  into  recommending  it.  The  opinions  here  expressed  are 
based  not  upon  prejudice,  but  actual  trial  in  private  prac- 
tice and  in  a  large  clinic,  with  every  facility  for  following  the 
subsequent  history  of  the  cases.  This  trial  was  made  before 
present  successful  surgical  methods  were  known.  It  was 
then,  perhaps,  excusable  to  test  a  method  which  now  seems 
so  crude  and  unscientific,  as  we  were  seeking  a  cure  for  hernia. 
The  ultimate  history  of  the  cases  injected  was,  as  a  rule,  that 
of  recurrence,  and  the  method  has  been  entirely  abandoned 
for  several  years.  Its  promoters  recommend  it  as  a  per- 
fectly safe  method.  Two  deaths  are  known  to  have  occurred 
from  its  use  within  the  past  few  years,  and  one  case  was  oper- 
ated upon  in  order  to  save  the  life  of  a  woman  who  had  been 
treated  by  a  notorious  (advertising)  advocate  of  the  injection 
method.  In  this  case,  his  needle  had  punctured  the  wall  of  the 
intestine  which  was  in  the  canal.  Inflammation  and  strangu- 
lation rapidly  supervened,  and  the  woman  was  in  a  condition  of 
collapse  when  first  seen.  An  immediate  operation,  with  the 
administration  of  oxygen  and  stimulants,  barely  saved  her  life. 


TREATMENT  BY  GYMNASTICS.  213 

It  is  fully  fifty  years  since  attempts  were  first  made  by 
Velpean  of  Paris,  Pancoast  of  Philadelphia,  and  others,  to  cure 
hernia  by  the  injection  of  an  irritatini^  substance  either  into 
the  sac  or  the  tissues  of  the  canal  around  the  neck  of  the  sac. 
Heaton  of  Boston,  a  few  years  later,  devised  a  formula  which 
he  used  secretly  for  thirty  years  and  then  published.^  The 
early  experimenters  used  for  injection  tincture  of  iodine, 
tincture  of  cantharides,  and  the  essential  oils.  Pleaton  used  a 
combination  of  the  solid  and  fluid  extracts  of  white-oak  bark, 
which  was  probably  better  than  the  formulae  more  recently 
used,  consisting-  of  chloride  of  zinc,  carbolic  acid,  cocaine,  etc. 
The  Heaton  method  was  deceptive,  as  a  certain  amount  of 
improvement  was  noticeable  in  every  case.  A  few  appeared 
cured  for  from  three  to  six  months,  but  unfortunately  with 
almost  the  entire  number  hernia  eventually  recurred.  From 
our  present  point  of  view,  the  method  cannot  be  too  strongly 
condemned. 

^  The  Cure  of  Rupture,  Geo.  Heaton,  M.D.,  Boston,  1877. 


CHAPTER  XL 

SURGICAL  CURE  OF  INGUINAL  HERNIA. 

In  the  great  advance  made  in  surgical  work  during  the 
past  few  years  the  special  surgery  relating  to  the  treatment  and 
cure  of  abdominal  hernia  has  occupied  a  foremost  place.  Per- 
haps, aside  from  pelvic  surgery,  no  other  branch  has  made  an 
equal  advance.  The  "  radical  cure  of  hernia  "  has  been  spoken 
of  for  many  years,  but  the  methods  were  not  radical  and  seldom 
cured.  There  were  operations  for  the  radical  cure,  trusses  for 
the  radical  cure,  and  still  the  fact  remained  that  very  few 
hernias  in  the  adult  were  ever  cured,  and  many  surgeons  had 
given  up  hope  of  seeing  this  very  common  affliction  placed 
on  the  list  of  curable  diseases. 

There  is  little  time  in  this  age  of  rapid  advancement  to 
discuss  past  failures,  except,  perhaps,  to  ask  why  they  failed. 
Recent,  and  very  large,  experience  has  answered  the  question 
in  a  perfectly  satisfactory  manner,  so  that  now  it  seems  strange 
that  light  did  not  come  to  us  before.  It  is  a  repetition  of  the 
old  story  of  Columbus  and  the  egg — after  he  had  shown  them 
how,  they  could  all  make  the  egg  stand  on  end.  The  Columbus 
in  the  present  instance  was  unquestionably  Bassini,  of  Padua, 
Italy.  ^  At  least  two  of  our  own  countrymen  had  devised  opera- 
tions which  would  eventually  have  led  to  success,  but  the  fact 
that  Bassini  published  an  operation,  complete  in  its  technique, 
and  supported  by  a  first  report  of  over  200  cases,  some  oper- 
ated on  several  years  previously,  makes  it  only  fair  that  we 
should  give  to  Italy  an  honor  which  we  should  have  been  only 
too  glad  to  claim  for  America. 

In  operating  to  cure  hernia  at  the  present  day  the  proposi- 
tion is  not  "  to  restore  the  canal  to  its  normal  condition,"  which 
attempt  failed  through  many  centuries,  but  to  construct  a  canal 
better  than  it  ever  was  before. 

^Arch.  f.  klin.  Chirg.  Vol.  xl,  1890,  p.  429. 
214 


SURGICAL  CURE.  215 

The  great  success  of  the  present  operation  lies  in  the 
thoroughness  with  which  all  abnormal  tissues  are  removed 
from  the  inguinal  canal  and  the  subsequent  correction  of  an 
anatomical  defect  which  exists  in  the  larger  part  of  the  human 
family.  The  failure  to  do  these  very  things,  and  the  general 
incompleteness  of  all  previous  operations,  are  the  very  good 
reasons  for  their  almost  uniform  failure  to  produce  permanent 
cure.  For  many  years  the  imperfect  operations  were  persisted 
in,  because  of  the  ever-present  fear  of  doing  anything 
surgically  that  would  approach  or  disturb  the  peritoneal  mem- 
brane or  cavity.  Furthermore,  it  was  long  believed  that  the 
persistence  of  the  hernial  sac  was  the  chief  cause  of  the  continu- 
ance of  the  hernia,  and  if  this  could  be  destroyed,  without 
injury  to  the  patient,  a  permanent  cure  would  result.  The 
attempts  to  cure  hernia  in  the  past  have  been  made  at  or  near 
the  external  ring,  while  now  the  corrections  begin  at  the  peri- 
toneal surface  and  continue  with  each  layer  until  the  skin  is 
closed.  This  is  truly  a  "  radical  "  operation  for  the  cure  of 
inguinal  hernia. 

The  preparation  of  the  patient  for  an  operation  for  hernia 
should  be  made  with  the  same  care  in  every  detail  that  would 
be  exercised  in  any  other  abdominal  operation.  There  is 
plenty  of  evidence  at  hand  to  indicate  that  discredit  will  be 
reflected  upon  the  modern  operation  for  the  cure  of  hernia  by 
those  undertaking  its  performance  who  would  not  think  of 
doing  any  other  abdominal  work.  This  is  sure  to  reflect 
against  the  operation  in  two  ways.  It  will  cause  a  mortality 
that  is  entirely  unjustifiable,  and  it  will  show  a  larger  percent- 
age of  failures  than  should  be  presented.  In  most  instances 
the  applicant  for  an  operation  for  the  cure  of  hernia  is  in  fairly 
good  general  health,  and  long  preparation  is  unnecessary.  It  is 
important  that  the  condition  of  the  heart,  lungs,  and  kidneys 
should  be  ascertained  in  order  to  intelligently  decide  upon  the 
form  of  anaesthesia  best  suited  for  the  case  under  considera- 
tion, and  this  should  be  done  before  the  patient  is  prepared 
for  operation. 


216  ABDOMINAL  HERNL\. 

AVhen  possible,  the  patient  should  be  under  the  control  of  a 
trained  nurse,  or  in  the  hospital  for  about  twenty-four  hours 
before  the  operation  is  performed,  to  insure  careful  preparation 
and  to  regulate  the  food  supply.  A  cathartic  should  be  given 
and  the  parts  prepared  the  night  before  the  operation.  If  the 
cathartic  is  not  effective,  an  enema  should  follow  in  the  morn- 
ing. The  preparation  of  the  field  of  operation  on  the  preceding 
night  consists  of  a  complete  shaving  of  the  entire  region,  the 
cleansing  and  application  of  a  liberal  green-soap  poultice,  held 
in  place  by  a  suitable  bandage,  usually  the  Spica.  In  the  morn- 
ing this  dressing  is  removed,  the  parts  thoroughly  cleansed  with 
sterilized  water,  followed  by  90  per  cent,  alcohol.  Gauze 
moistened  in  a  one  to  2,000  solution  of  bichloride  of  mercury 
is  then  applied  under  a  bandage  and  left  in  place  until  the 
patient  is  on  the  operating  table.  Here  the  field  of  operation  is 
again  scrubbed  with  liquid  soap  and  a  sterilized  brush,  and 
washed  off  with  sterilized  water,  followed  by  a  one  to  2,000 
solution  of  bichloride  of  mercury.  Sterilized  towels  should 
now  be  spread  so  as  to  cover  the  entire  patient,  except  the 
immediate  field  of  operation,  and  all  chemical  solutions  thrown 
away.  No  fluids,  except  sterilized  water,  or  normal  saline 
solution,  should  be  used  during  the  operation. 

Every  person  connected  with  the  operation  in  any  way 
should  prepare  in  the  most  careful  manner.  Many  methods 
have  been  tried,  but  none  has  been  found  better  than  first  scrub- 
bing the  fingers,  hands,  and  arms  to  the  elbows  with  soap  in 
water  that  has  been  boiled,  then  washing  in  alcohol,  followed 
bv  a  thorough  washing  in  a  one  to  2,000  solution  of 
bichloride  of  mercury.  The  finger  nails  are  doubtless  the  most 
frequent  carriers  of  disease  germs,  and  they  should  be  given 
the  utmost  care.  They  should  be  cut  and  filed  down  as  near 
the  "  quick  "  as  possible,  and  then  in  cleansing  should  receive 
special  care  and  scrubbing.  Sterilized  rubber  gloves  should 
be  worn,  but  the  use  of  these  should  be  preceded  by  the  same 
careful  scrubbing  and  chemical  sterilization  as  though  they 
were  not  to  be  worn. 


SURGICAL  CURE.  217 

Bassini  Operation. — In  the  surgical  cure  of  inguinal 
hernia,  the  work  of  the  leading  operators  has  crystalHzed  into 
the  following  essentials,  and  while  the  operation  is  done  under 
various  names,  it  appears  to  the  author  that  Bassini  was  the 
hrst  to  demonstrate  their  importance. 

( I )  The  complete  removal  from  the  inguinal  canal  of  all 
foreign  tissue  (sac,  fat,  abnormal  vessels).  (2)  Utilizing  the 
fascial  layers  about  the  canal  to  so  fortify  it  as  to  prevent 
recurrence.  (3)  The  execution  of  the  work  with  extreme 
asepsis  to  ensure  safety  and  prompt  healing. 

Almost  all  operators  select  some  form  of  suture  material 
not  quickly  absorbed,  but  few  in  this  country  now  follow 
Bassini  in  the  use  of  silk.  Every  operator  of  experience  will 
modify  the  operation  to  meet  the  special  indications  of  the  case 
in  hand.     Briefly,  the  Bassini  operation  is  as  follows : 

( 1 )  An  incision  through  the  skin,  fatty  tissue,  and 
aponeurosis  of  external  oblique  muscle,  wdiich  exposes  the  canal 
in  its  entire  length. 

(2)  The  sac  is  opened,  its  contents  reduced  and,  after 
double  ligation  of  its  neck  flush  with  the  peritoneum,  it  is  cut 
away.     Any  other  tissue  foreign  to  the  canal  is  removed. 

(3)  The  cord  is  held  aside  and  the  lower  border  of  the 
internal  oblique  and  transverse  muscles  attached  to  Poupart's 
ligament  by  interrupted  sutures  (silk  according  to  Bassini,  per- 
sonally a  continuous  suture  of  kangaroo  tendon  is  preferred). 

(4)  The  cord  is  placed  upon  the  muscular  wall  and  the 
aponeurosis  and  skin  closed  over  it  in  separate  layers. 

To  Dr.  Henry  O.  Marcy  of  Boston,  a  pioneer  in  modern 
methods  for  the  cure  of  hernia,  we  are  under  obligations  for 
showing  us  the  value  of  kangaroo  tendon.  It  is  an  almost 
ideal  suture  material  for  the  deep  buried  sutures  of  hernia 
operations.  We  believe  also  that  he  was  the  first  to  use  the 
subcutaneous  stitch  for  the  closure  of  the  skin ;  two  things 
which  add  materially  to  the  success  of  this  operation.  Aly  own 
modification  of  the  Bassini  operation  has  been  principally  in 
the  use  of  the  kangaroo  tendon,  and  in  using  a  continuous 


218  ABDOMINAL  HERNIA. 

instead  of  an  interrupted  suture.  In  individual  cases,  it  would 
seem  that  I  had  made  ahnost  every  possible  modification  to 
meet  the  exigencies  of  the  case  in  hand.  Details,  of  the  opera- 
tion used  in  over  1,200  cases  of  inguinal  hernia,  follow. 

OPERATION. 

Oblique  Inguinal  Hernia. — In  planning  the  incision,  cer- 
tain anatomical  landmarks  must  be  observed,  and  the  first  of 
these  is  to  locate  accurately  the  external  ring.  In  thin  subjects 
this  is  not  difficult,  as  it  is  readily  felt  through  the  skin  and  sub- 
cutaneous fat,  but  where  there  is  a  thick  deposit  of  adipose 
tissue  it  is  not  such  an  easy  matter.  It  has  been  found  that  in 
a  majority  of  cases,  with  male  patients,  the  most  satisfactory 
way  is  to  roll  the  spermatic  cord  between  the  fingers  and  the 
pubic  bone,  following  it  up  to  its  point  of  entrance  into  the 
abdominal  wall,  this  giving  accurately  the  external  ring.  The 
same  test  answers  equally  well  in  the  female  in  most  instances, 
as  the  thickened  sac  and  its  covering  of  fascia  have  very  much 
the  feeling  of  the  cord  in  the  male.  Locate  Poupart's  ligament 
by  placing  a  finger  upon  the  anterior  superior  crest  of  the  ilium 
and  another  upon  the  spine  of  the  pubes.  An  imaginary  line 
slightly  curved  downwards  between  these  two  points  represents 
the  ligament.  In  the  adult  the  incision  should  be  parallel  with 
and  about  one  inch  towards  the  median  line  from  Poupart's 
ligament,  and  from  three  to  four  inches  long,  according  to  the 
patient.  In  very  fat  patients,  a  much  longer  incision  will  be 
required  through  which  to  do  good  work  than  in  those  who  are 
thin.  The  operation  has  been  done  frequently  on  adults  by  the 
author  through  an  incision  one  and  a  half  inches  long,  but  this 
should  be  attempted  by  those  only  who  are  thoroughly  familiar 
with  the  work. 

The  incision  passes  through  the  skin  and  the  superficial 
and  deep  layers  of  fascia  to  the  aponeurosis  of  the  external 
oblique  muscle.  No  attempt  need  be  made  to  recognize  the 
two  layers  of  fascia,  as  in  many  instances  they  cannot  be  dis- 
tinguished.    In  others,  however,  the  dividing  line  is  so  clearly 


SURGICAL  CURE.  219 

marked  as  to  lead  the  operator  to  belie\e  that  he  has  ah'eady 
reached  the  aponeurosis.  The  latter  should  be  recognized  by 
its  white,  glistening  surface  and  the  direction  of  its  fibres.  The 
lower  end  of  the  incision  should  terminate  at  the  upper  edge  of 
the  pubic  bone,  and  its  upper  end  should  be  well  above  the 
internal  ring.  Even  in  very  large  scrotal  hernicC,  it  is  neither 
necessary  nor  is  it  advisable  to  extend  the  incision  into  the 
scrotal  tissues,  as  the  whole  scrotal  tumor  and  sac  can  be  turned 
out  through  the  inguinal  incision.  If  this  incision  is  of  full 
length,  both  the  superficial  epigastric  and  superficial  pubic  ves- 
sels will  be  cut  and  require  clamping.  In  many  instances  if 
the  clamps  remain  on  during  the  following  steps  of  the  opera- 
tion up  to  the  closure  of  the  skin,  ligature  of  the  vessels  will 
not  be  required.  If  the  patient  is  fat,  the  clamps  will  obstruct 
the  operative  field,  and  it  is  better  to  tie  the  vessels  at  once  or 
close  them  by  torsion.  There  should  be  no  uncertainty  as  to 
their  complete  closure,  as  subsequent  oozing  would  almost 
certainly  preclude  primary  union. 

At  this  stage  of  the  operation,  the  beginner  frequently  has 
trouble  in  locating  the  external  ring,  and  this  is  because  it  is 
partially  covered  by  the  intercolumnar  fascia.  This  fascia  can 
readily  be  scraped  away  from  above  downwards  by  the  handle 
of  the  scalpel  or  the  grooved  director.  The  director  can  then 
be  slipped  through  the  external  ring  up  under  the  aponeurosis 
of  the  external  oblique  muscle,  and  the  latter  is  split  in  the 
direction  of  its  fibres  to  a  point  a  little  above  the  internal  ring. 
The  inner  split  edge  is  taken  by  a  clamp  and  the  aponeurosis  is 
stripped  away  from  the  internal  oblique  muscle  towards  the 
median  line  by  slipping  the  fingers  between  the  two.  The  outer 
split  edge  is  clamped  and  all  fascia  removed  from  inner  surface 
down  to  Poupart's  ligament.  The  clamps  should  be  allowed  to 
remain  on  the  flaps  as  a  guide.  The  whole  extent  of  the  canal 
is  now  wide  open,  and  still,  in  many  instances,  the  sac  is  not 
visible  and  the  beginner  is  perplexed  as  to  its  whereabouts, 
doing  actual  harm  in  some  instances  by  cutting  muscular  fibre 
that  should  never  be  divided.     In  fact,  no  muscular  fibre  should 


220  ABDOMINAL  HERNIA. 

be  cut  in  this  operation.  ]\Iuscle  may  be  split  and  it  will  reunite 
without  harm  to  its  function;  but  once  cut  across  its  fibre, 
it  is  doubtful  whether  it  will  ever  return  to  its  former  useful- 
ness and  strength.  The  ilio  inguinal  nerve  will  usually  be  seen 
passing  down  over  the  sac  and  should  be  lifted  up  and  put  out- 
side of  one  of  the  clamps  holding  the  aponeurosis,  in  order  to 
protect  it  from  injur}^ 

In  finding  the  sac,  pick  up  with  thumb  forceps  the  tissue 
presenting  most  prominently  at  the  lower  deep  part  of  the 
wound,  and  almost  invariably  it  will  lead  to  the  sac.  The  sac 
and  the  cord  should  now  be  lifted  out  of  the  canal  together. 
The  sac  is  covered  by  fascia  that  it  has  picked  up  from  the  edge 
of  the  muscles  in  its  progress  down  the  canal,  and  this  can  be 
readily  divided  by  any  blunt  instrument.  The  cord  should  now 
be  separated  from  the  sac,  and  this  is  often  attended  by  diffi- 
culty. It  should  be  done  by  blunt  dissection,  and  better  by  the 
fingers  than  by  instruments.  It  is  accomplished  by  carefully 
stripping  one  from  the  other,  and  the  first  point  of  separation 
should  be  as  near  the  internal  ring  as  possible.  Many  have 
failed  in  this  part  of  the  operation  by  trying  to  separate  them  at 
a  point  lower  down.  This  is  especially  true  in  congenital 
hernia.  The  separation,  to  be  accomplished  at  all,  must  begin 
as  near  the  peritoneal  surface  as  possible.  At  this  point  it  can 
be  done  in  almost  every  case,  and  it  is  one  important  element  in 
the  success  of  the  operation. 

Especial  caution  is  necessary  in  separating  the  vessels  of 
the  cord  from  the  sac  not  to  tear  them,  and  it  has  been  found 
most  convenient  and  satisfactory  to  do  this  by  clearing  all  tissue 
from  the  sac  at  one  point  and  then  to  roll  the  sac  in  one  direc- 
tion over  the  finger  end  while  all  tissues  and  vessels  are  cleared 
off  by  and  held  in  the  fingers  of  the  other  hand.  The  vas 
deferens,  next  to  the  artery  of  supply,  is  the  most  important 
vessel  of  the  cord  and  the  most  likely  to  be  overlooked,  as  in 
color  it  is  white  like  the  sac.  Its  location  can  always  be  ascer- 
tained by  rolling  the  tissues  between  the  thumb  and  fingers 
under  considerable  pressure.     Its  hard,  wiry  feeling  is  char- 


SURGICAL  CURE. 


221 


acteristic.    Communicating  vessels  broken  while  stripping  away 
the  sac,  if  at  all  important  and  on  the  cord,  should  be  tied  at 

Fig.  109. 


Showing,  A,  sac  separated  from  cord  ;  B,  cord  held  up  by  blunt  hook  ;  C,  lower  border  of 
internal  oblique  and  transversalis  muscles  ;  D,  epigastric  vessels,  crossing  wound  transversely 
beneath  internal  oblique;  E,  split  aponeurosis  of  external  oblique  held  back  by  clamps  on 
either  side,  showing  Poupart's  ligament  at  extreme  inner  border. 

once,  as,  if  lost  to  view,  they  are  hard  to  find  again.  Bleeding 
vessels  on  the  sac  surface  are  unimportant,  as  the  entire  sac  is 
to  be  removed  after  ligation  (fig.  109). 


222  ABDOMINAL  HERNL4. 

The  sac  should  in  every  instance  be  opened  and,  if  found 
empty,  its  neck  hgated  after  clearing  it  of  all  vessels  and  fat. 
Where  the  size  of  the  sac  will  permit,  it  is  considered  best  that 
the  operator  hold  the  finger  of  one  hand  well  within  its  neck, 
while  the  assistant  ties  down  on  the  end  of  the  finger.  As  the 
pressure  of  the  ligature  is  felt  around  the  end  of  the  finger,  the 
latter  is  withdrawn.  By  this  method  there  is  little  danger  of 
including  a  loop  of  bowel  or  piece  of  omentum  within  the  liga- 
ture. After  the  first  ligature  has  been  completed,  the  sac 
should  be  perforated  just  outside  of  it,  surrounded  and 
ligatured  again  b}-^  the  same  strong  catgut.  In  this  manner 
two  complete  ligatures  with  perforation  between  them  prevent 
the  slipping  off  of  either.  The  sac  should  be  cut  away  before 
cutting  the  ligature,  as  by  the  latter  the  stump  can  be  controlled 
and  it  can  be  seen  that  there  is  no  bleeding.  Ordinarily  there 
are  no  important  vessels  in  the  sac  wall,  but  there  are  very 
important  exceptions  to  this  rule,  and  a  case  is  known  where  a 
young  operator  cut  the  sac  without  tying,  expecting  to  close  it 
as  in  an  ordinary  cceliotomy.  Hsemorrhage  resulted,  which 
could  not  be,  or  at  least  was  not,  found,  and  which  proved  fatal 
to  the  patient.  Another  case  was  seen  in  consultation  where 
the  operator  had  failed  to  find  the  bleeding  vessel.  While  the 
sac  is  being  ligated,  traction  should  be  made  upon  it  so  as  to 
draw  it  well  up  into  the  wound.  In  this  manner  the  ligature 
is  placed  flush  with  the  peritoneal  surface,  and  when  the  sac 
is  cut  away  it  leaves  no  pocketing  of  peritoneum  from  within — 
the  intra-abdominal  surface  is  left  practically  smooth  at  this 
point. 

An  accident  that  must  be  guarded  against,  at  this  stage  of 
the  operation,  is  the  looping  up  of  the  spermatic  vessels  on  the 
neck  of  the  sac  and  their  subsequent  ligation.  As  the  sac  is 
tied,  the  operator  should  make  traction  on  it  so  as  to  draw  its 
neck  well  up  into  the  wound.  When  it  is  tied  and  cut,  it  will 
retract  and  the  peritoneal  surface  will  become  smooth  upon  its 
inner  surface  at  the  site  of  the  internal  ring.  The  canal  should 
be  cleared  of  all  loose  fat  or  other  abnormal  tissue,  and  the 


SURGICAL  CURE.  223 

operator  is  then  ready  to  begin  its  closure,  and  upon  the 
thoroughness  and  care  with  which  this  is  done  will  depend 
to  a  very  great  extent  the  permanence  of  the  cure.  With 
the  canal  wide  open  and  freed  from  the  sac,  it  will  be  seen  that 
there  is  a  triangular  space  back  of  the  cord,  which  is  entirely 
unprotected  by  muscular  or  tendinous  structure.  In  fact,  there 
is  usually  nothing  but  peritoneum  and  its  overlying  fascia. 
This  triangle,  with  its  apex  directed  towards  the  iliac  crest,  is 
formed  above  by  the  lower  border  of  the  internal  oblique 
muscle,  below  by  Poupart's  ligament,  and  the  pubic  bone  forms 
its  base.  This  muscular  defect  is  overcome  (in  this  operation) 
by  freeing  the  lower  part  of  the  internal  oblique  and  trans- 
versalis  muscles  from  their  connections  above  and  below, 
slipping  them  down  and  stitching  their  lower  border  to 
Poupart's  ligament. 

Fig.  iio. 


Blunt  needle  (actual  size)  used  in  placing  kangaroo  tendon  sutures  in  the  deep 
muscular  tissue  and  the  aponeurosis  of  external  oblique. 

The  connective  tissue  between  the  aponeurosis  of  the 
external  oblique  and  the  internal  oblique  has  been  separated  in 
the  earlier  part  of  operation.  The  internal  oblique  and  trans- 
versalis  should  now  be  freed  from  their  deep  connections  by 
gently  passing  the  finger  along  under  their  lower  border. 
When  the  deep  muscles  are  thus  freed  above  and  below,  their 
lower  border  can  be  brought  into  contact  with  Poupart's  liga- 
ment without  undue  tension.  With  a  strong,  blunt,  curved 
needle  (fig.  no)  threaded  with  heavy  kangaroo  tendon,  the 
lower  borders  of  the  deep  muscles  are  perforated  well  liack 
from  their  edges,  and  at  a  point  over  the  internal  ring.  The 
cord  is  held  up  by  a  blunt  hook,  or  by  the  finger  of  an  assistant. 


224 


ABDOMINAL  HERNIA. 


the  needle  passed  beneath  it  and  through  Poupart's  Hgament, 
high  up.     When  the  suture  is  tied,  it  will  be  found  that  the 


Fig.  III. 


A,  cord  held  up  by  blunt  hook  ;  B,  internal  oblique  stitched  to  Poupart's  ligament  by  kan- 
garoo tendon  :  continuous  suture  made  by  passing  suture  over  point  of  needle  each  time  after 
puncture  of  tissue,  and  before  tightening  the  thread;  C,  aponeurosis  held  by  clamps  on  both 
sides. 

lower  Ijorfler  of  the  internal  obli(jue  surrounds  the  cord  closely. 
The  muscle  is  now  stitched  to  the  ligament  throughout  the 


SURGICAL  CURE. 


225 


length  of  the  canal  from  the  internal  ring  to  the  pubic  bone 
(fig.  III).  -\n  interrupted  suture  can  be  used  if  preferred, 
but  the  continuous  is  believed  better,  as  it  does  away  with  the 


Fig.   112. 


Aponeurosis  of  external  oblique  closed  over  cord  by  continuous  suture  of  kangaroo  tendon. 


numerous  knots  and  can  be  put  in  more  rapidly.  An  additional 
suture  placed  above  the  cord  has  been  suggested  by  Dr.  ^^^  B. 
Coley.  I  have  occasionally  used  this  extra  suture  above  the 
cord,  but  have  usually  preferred  to  crowd  the  cord  up  into  the 
15 


226  ABDOMINAL  HERNIA. 

extreme  upper  angle  of  the  wound,  making  the  canal  as  long  as 
possible.  The  cord  is  placed  on  this  muscular  wall,  which  has 
been  constructed  beneath  it,  and  the  split  aponeurosis  closed 
over  it  by  kangaroo  tendon  with  the  same  stitch   (fig.   112). 

The  split  made  in  the  aponeurosis  is  C[uite  likely  to  extend 
up  under  the  intercolumnar  fascia,  and  its  appearance  is  there- 
fore deceptive.  The  first  suture  should  be  taken  an  inch,  if  pos- 
sible, above  the  apparent  split,  otherwise  a  weak  place  is  left, 
inviting  recurrent  hernia.  It  is  neither  necessary  nor  advisable 
that  the  aponeurosis  be  brought  together  edge  to  edge.  It  is 
better  that  the  needle  punctures  be  well  back  from  the  edge  and 
not  all  in  the  same  line.  The  closing  of  the  skin  by  the  sub- 
cutaneous (buried)  suture  and  the  sealing  of  the  wound  by 
collodion,  complete  the  operation.  A  compress  of  folded, 
sterilized  gauze,  held  in  place  by  adhesive  strips  across  the  hips, 
with  a  liberal  spica  bandage,  form  the  dressings. 

Drainage  need  not  be  used  except  in  enormous  scrotal 
herniae,  where  the  stripping  out  of  the  sac  is  liable  to  leave  con- 
siderable oozing.  In  these  cases  a  rubber  drainage  tube  is 
carried  through  the  bottom  of  the  scrotum  and  left  in  for 
twenty- four  hours.  During  this  time  its  outer  end  is  care- 
fully protected  by  moist  bichloride  gauze.  The  upper  wound 
is  completely  closed  and  sealed  in  the  manner  described.  The 
bandage  and  dressings  on  the  hernial  wound  are  not  removed 
for  ten  days  unless  the  elevation  of  temperature  or  pain 
demands  it.  An  elevation  of  temperature  on  the  day  following 
the  operation  is  not  considered  as  indicating  the  removal  of  the 
dressings,  but  when  it  occurs  about  the  fifth  day  it  is  sus- 
picious, pointing  to  wound  infection.  Under  proper  aseptic 
work,  deep  infection  is  never  seen,  and  that  which  does  occur  is 
superficial,  coming  largely  from  the  skin.  The  skin  in  old 
truss  wearers  is  frequently  in  particularly  bad  condition,  and 
no  amount  of  cleaning  will,  with  certainty,  sterilize  it.  When 
such  infection  does  occur,  the  dressings  should  be  removed  and 
the  wound  cleansed  daily  with  some  good  antiseptic.  I  have 
found  nothing  better  than  borolyptol  for  this  purpose.     Delayed 


SURGICAL  CURE.  227 

healing  does  not,  as  has  been  claimed,  prevent  a  permanent  cure 
of  the  case.  It  is  certain!}^  undesiraljle,  but  not  a  serious  coni- 
pHcation. 

There  are  certain  pecuharities  of  sac  formation  that 
demand  shght  modification  in  the  operation.  In  congenital 
hernia,  it  is  not  essential  that  the  entire  tunica  vaginalis  should 
be  stripped  away  from  the  cord  and  front  of  the  testicle.  That 
portion  which  occupies  the  canal,  from  the  peritoneal  surface  to 
nearly  the  top  of  the  testicle,  should  be  separated  from  the  cord 
and  excised  with  ligatures  applied  at  both  the  upper  and  lower 
points.  There  are  instances  also  where  it  may  not  be  advisable 
to  remove  the  fundus  of  a  very  large  accpiired  sac  from  the 
scrotum,  and  the  communicating  vessels  are  quite  large  enough 
to  prevent  its  sloughing  after  the  excision  of  the  neck.  This 
leaves  cjuite  a  mass  of  thickened  tissue  in  the  scrotum  and  the 
possibility  of  hydrocele  occurring  within  the  sac,  so  that  unless 
there  is  some  good  reason  for  not  doing  so  it  is  better  practice 
to  remove  it.  In  old  and  feeble  men,  it  is  much  more  im- 
portant to  terminate  the  operation  with  the  greatest  possible 
speed,  than  it  is  to  be  certain  that  no  particle  of  thickened 
tissue  shall  remain  in  the  scrotum. 

It  is  the  opinion  of  the  author  that  the  Bassini  method  as 
described,  meets  in  an  ideal  manner  the  indications  for  the 
operative  cure  of  ordinary  cases  of  oblique  inguinal  hernia.  It 
is  desirable,  however,  that  every  operator  should  be  familiar 
with  certain  important  modifications  that  may  be  necessarv  in. 
cases  where  closure  is  extremely  difficult. 

In  1895,  Dr.  Edward  Wyllys  Andrews  of  Chicaga 
("Imbrication  or  Lap-joint  Method,"  "A  Plastic  Operation 
for  Hernia,"  CJiicago  Medical  Recorder,  Aug..  1895)  sug- 
gested that  in  certain  cases  where  there  was  great  deficiencv  of 
the  internal  oblique  and  conjoined  tendon,  increased  strength 
could  be  obtained  by  "  Imbrication  ''  or  overlapping  of  the 
fascial  layers  (see  also  Surgery,  Gynecology,  and  Obsfe fries, 
vol.  ii,  p.  89,  January,  1906).  This  he  accomplished  in  the 
following  manner : 


228  ABDOMINAL  HERNIA. 

The  opening  of  the  canal  and  treatment  of  the  sac  were 
m  every  particular  similar  to  the  Bassini  operation.  In  closing, 
however,  the  split  aponeurosis,  and  whatever  of  the  deficient 
internal  oblique  could  be  obtained,  were  brought  down  together 
and  stitched  to  Poupart's  ligament  under  the  cord.  The  cord 
was  then  laid  upon  this  wall,  and  the  remaining  outer  flap  of 
the  split  aponeurosis  brought  over  it  and  edges  stitched 
down  to  aponeurosis. 

This  method  places  back  of  the  cord  the  aponeurosis  of  the 
external  and  internal  oblique  muscles,  and  in  front  of  it  the 
additional  overlapping  layer  of  the  aponeurosis  of  the  external 
oblique.  This  would  seem  to  utilize  to  the  fullest  extent  the 
defective  material  that  we  may  sometimes  have  to  work  with 
and  the  method  has  been  used  by  the  author  on  several  cases 
with  good  results.  Dr.  Andrews  says  in  his  first  paper,  •"  I 
make  use  of  it  to  supplement  and  reinforce  existing  methods 
without  losing  sight  of  their  good  qualities,"  but  in  his  more 
recent  article  he  declares  that  he  has  adopted  it  as  a  routine 
method.  A  somewhat  similar  operation  has  been  elaborated 
at  the  Johns  Hopkins  Hospital  by  Dr.  Halsted  and  Dr.  Blood- 
good  ("  The  Cure  of  the  More  Difficult  as  Well  as  the  Simpler 
Inguinal  Ruptures,"  W.  S.  Halsted,  M.D.,  Johns  Hopkins 
Hospital  Bulletin,  Aug.,  1903). 

In  presenting  this  operation,  I  certainly  cannot  do  better 
than  to  give  it  in  Dr.  Halsted's  own  words,  and  by  the  repro- 
duction of  the  beautiful  plates  by  Brodel: 

The  Operation. 

"(i)  The  aponeurosis  of  the  external  muscle  is  divided 
and  the  two  flaps  reflected  as  in  the  Bassini-Halsted  operation. 

"  (2)  The  cremaster  muscle  and  fascia  are  split,  not  di- 
rectly over  the  cord,  iDut  a  little  above  it. 

"  (3)  The  internal  oblique  muscle  is  made  as  free  as  pos- 
sible. A  little  arti faction  is  here  often  necessary.  If  the 
muscle  cannot  be  drawn,  without  tension,  down  to  Poupart's 
ligament,  it  helps,  I  think,  to  make  a  relaxation  cut  or  two  in 


SURGICAL  CURE. 


229 


the  anterior  sheath  of  the  rectus  muscle  under  the  aponeurosis 
of  the  external  oblique  muscle.  This  sheath  being  in  part  the 
aponeurosis  of  the  internal  oblique  muscle,  one  can  readily 
comprehend  that  incisions  into  it,  if  properly  made,  mig-ht  be  of 
service.  It  is  well,  however,  to  postpone  making  such  incisions 
until  the  sewing-  of  the  internal  oblicjue  muscle  to  Poupart's 
ligament  is  begun,  for  then  the  amount  of  tension  can  l)e  nicely 
gauged  and  the  number,  length,  and  precise  position  of  the 

Fig.  I 13. 


Showing  relalive  position  of  sac,  cord  and  vas  deferens  ;  method  of  haiidHng.    {Hahtfd  ) 


relaxation  cuts  determined.  A  second  reason  for  postponing 
relaxation  incisions  into  the  anterior  sheath  of  the  rectus  muscle 
is  that  we  sometimes  use  this  portion  of  the  rectus  sheath  to 
close  the  lower  part  of  the  inguinal  canal,  as  already  stated. 
"  (4)   When  the  veins  are  large,  and  this  is  usually  the 


230 


ABDOMINAL  HERNIA. 


case,  they  should  be  excised  with  very  great  care  to  avoid  even 
the  slightest  extravasation  of  blood  into  the  tissues  about  the 
smaller  veins  and  about  the  vas  deferens  which  they  accom- 
pany. And  the  vas  deferens,  as  first  emphasized  by  Blood- 
good,  should  not  be  raised  from  its  bed  or  handled  or  even 
touched,  lest  thrombosis  of  its  veins  occur  (fig.  113).      The 


Fig.  114. 


Showing  the  cremaster  being  fastened  under  the  internal  oblique  muscle  by  fine  silk  sutures. 

{Halsied.) 

veins  should  be  ligated  as  high  up  in  the  abdomen  as  pos- 
sible, being  pulled  down  quite  firmly  just  before  the  ligature 
(in  a  needle  with  blunt  end  first)  is  passed  between  them. 
As  a  precaution  against  slipping,  we  apply  two  ligatures  of 
tine  silk,  both  for  the  abdominal  stump  and  for  the  testicle 
stump  of  the  veins.  The  farther  from  the  testicle  the  veins  are 
divided,  the  better,  provided,  of  course,  that  their  stump  is 
external  to  the  external  abdominal  rine. 


SURGICAL  CURE. 


231 


"  (5)  Ligation  of  the  sac  by  transfixion  or  by  purse-string 
suture  at  the  highest  possil)le  point.  Both  ends  of  this  suture, 
after  tying,  are  threaded  on  long  curved  needles,  then  carried 
far  out  under  the  internal  oblique  muscles  from  behind  for- 
wards, and,  passing  through  the  muscle,  about  5  mm.  apart. 
are  tied.  The  idea  was  suggested  to  the  author  by  Kocher's 
operation,  the  principle  being  essentially  the  same. 

Fig.  115. 


.1 

1 1  /  \li 

/ 

/            / 

I          /      / 

/ 

1 

\^^l 

telS^^T' 

^^jk 

-.^» 

^"M 

Ws^  '^^^Tr'"' 

\.-''     '        /     / 

pi 

1 

^ 

t' 

iii 

i 

"^^^S 

iy 

• 

'x%^SnH 

^S^^^ 

"""^^Bk 

KbSS^ 

■ 

c 

■  fmatter'           ;gH 

fl 

l^ij'"' 

n 

^g 

m 

■ 

1 

1 

Internal  oblique  sutured  to  Pouparl's  ligament  by  catgut.    {Halsted.) 


"  (6)  The  lower  flap  of  the  cremaster  muscle  and  its  fascia 
is  drawn  up  under  the  mobilized  internal  oblique  muscle  and 
held  in  this  position  by  very  fine  silk  stitches,  which,  having 
engaged  firmly  a  few  bundles  of  the  cremaster.  perforate  the 
internal  oblique,  preferably  where  it  is  becoming  aponeurotic, 
and  are  tied  on  the  external  surface  of  the  latter   (fig.   114). 

"  (7)  The  internal  oblique  muscle,  mobilized,  and  possibly 
further  released  by  incising  the  anterior  sheath  of  the  rectus 
muscle,  is  stitched   (the  conjoined  tendon  also)   to  Poupart's 


232 


ABDOMINAL  HERNIA. 


ligament  in  the  Bassini-Halsted  manner  (fig.  115).  Catgut 
is  usually  employed  for  this  suture.  The  drawing  was  made 
from  an  unusually  muscular  subject  and  possibly  exaggerated 
the  size  and  extent  of  the  internal  oblique  muscle,  as  well  as  of 
the  cremaster,  although  the  artist  endeavored  to  record  accu- 
rately what  he  saw. 

"  (8)  The  aponeurosis  of  the  external  oblique  muscle  is 
overlapped,  as  shown  in  figs.  116  and  117.  This  is  known  as 
Andrews'    method    {The    Chicago   Medical  Recorder,   Aug., 

Fig.  n6. 


Overlapping  of  the  aponeurosis  of  the  external  oblique,  first  step.  {Halsted.) 

1895,  vol.  ix,  p.  67),  although  devised  independently  by  us.* 
"  (9)  The  skin  is  closed  with  a  buried  continuous  silver 
suture,  and  the  incision  covered  with  five  or  six  layers  of  silver 
foil.  It  is  unnecessary  to  dress  or  examine  a  wound  closed  in 
this  manner  for  two  weeks,  when  the  wire  may  be  withdrawn. 


*  April  13,  14,  igo6,  Dr.  Bloodgood  demon.strated  before  the  Society 
of  Clinical  Surgery  (Surgery-Gynecology  and  Obstetrics,  June,  1906) 
his  present  rhethod  of  operating  upon  inguinal  hernia  without  transplant- 
ing the  Cord,  using  the  internal  oblique  fascia  instead  of  the  rectus  for 
closing  large  hernial  openings. 


SURGICAL  CURE. 


233 


Patients  are  kept  in  bed  for  a  period  of  eighteen  to  twenty- 
one  days." 

This  operation  differs  from  the  Bassini  method  in  the  fol- 
lowing particulars.  First,  that  the  essential  part  of  the  cord, 
the  vas  deferens  and  its  associated  vessels,  is  not  lifted  from  its 
normal  position.  Second,  in  the  ligation  of  a  part  of  the 
vessels  of  the  cord  in  most  instances ;  and,  third,  in  the  closure 
of  the  fascial  layers  by  overlapping.     While  I  have  great  confi- 

FiG.  117. 


Overlapping  of  the  aponeurosis  of  the  external  oijlique,  beeond  sit)).    \Hahttd.) 

dence  in  this  operation,  and  its  use  in  the  hands  of  its  author 
and  others  has  proven  its  value,  it  has  not  been  adopted  by  me 
for  the  following  reasons :  In  getting  99  per  cent,  permanent 
cures  by  the  Bassini  operation,  I  have  felt  that  more  could 
hardly  be  expected  from  any  method.  I  have  also  been  timid, 
perhaps  unnecessarily  so,  about  closing  the  canal  without  trans- 
fer of  the  cord,  as  it  did  not  seem  possible  to  me  to  get  as  strong 
a  closure.  Excision  of  the  veins  I  have  long  used  in  excep- 
tional cases  where  the  cord  was  uncommonly  large.     In  many 


234 


ABDOMINAL  HERNL\. 


of  the  cases   a   regular  varicocele   operation   has  been   done 
through  the  inguinal  incision. 

In  the  displacement  of  the  cord  several  modifications  of 
the  Bassini  method  have  been  suggested,  one  of  the  most  recent 
being  by  AA'ullstein  of  Halle  (Cciitralblatt  fur  Chirurgic,  no. 
38,  1906,  Beilage).  His  incision  starts  at  the  pubic  spine  and 
makes  a  bow-shaped  curve  upward  and  outward  to  the  neigh- 
borhood of  the  internal  ring,  one  or  two  finger-breadths  above 
Poupart's  ligament,  and  the  skin  flap  is  reflected  downward 
to  it.  The  aponeurosis  is  split  as  in  the  Bassini  operation, 
and  the  sac  removed.      The  cremaster  fibres   are   separated 

Fig.  tiS. 


Sectional  view  of  fascial  layers  in  completed  operation.     {Hoisted.) 

from  the  cord,  but  not  otherwise  disturbed.  The  transversalis 
fascia  is  now  split,  being  careful  not  to  injure  the  epigastric 
vessels,  and  the  cord  displaced  backward  upon  the  extra- 
peritoneal fat.  The  external  and  internal  oblique  muscles, 
transversalis  muscle  and  fascia,  are  then  all  stitched  to  Pou- 
part's ligament  throughout  the  canal  to  near  the  external  ring, 
as  shown  in  fig.  119.  A  flap  is  then  made  from  the  outer 
two-thirds  of  the  anterior  rectus  sheath  as  shown  in  the  cut, 
and  the  cord  is  transferred  from  the  external  ring  to  the  upper 
angle  of  this  incision.  The  fibres  of  the  rectus  muscle  are  then 
dissected  and  the  end  of  the  flap  stitched  beneath  them  and 
the  cord  as  shown  in  fig.  120.     AMien  the  sutures  are  tied  the 


SURGICAL  CURE. 


235 


aponeurotic  flap  is  pulled  l)ehiiKl  the  rectus  muscle,  and  the  cord 
assumes  a  course  running  well  behind  the  same  muscle,  curving 
outward  and  downward  to  reach  the  scrotum.  The  gap  in 
the  rectus  muscle  is  repaired  by  stitching  its  edges  together. 
In  a  series  of  1,500  children  under  fourteen  years  of  age, 
operated  upon  at  the  Hospital  for  Ruptured  and  Crippled,  New 
York,  on  125  the  cord  was  not  transplanted,  and  there  were  5 

Fig.  119. 


'    i 


Cord  placed  next  the  peritoneum,  tissues  stitched  over  it  to  Poupart's  ligament ;   flap  cut  in 
aponeurosis,  into  upper  angle  of  which  cord  is  to  be  transferred. 

relapses,  while  in  1,076  Bassini  operations  there  were  only  6 
recurrences  ("Results  of  1,500  Operations  for  the  Radical 
Cure  of  Hernia  in  Children,"  Wm.  T.  Bull  and  Wm.  B.  Coley, 
N.  Y.  Med.  Record,  March  18,  1905).  These  results  confirm 
my  long  established  belief  that  the  transfer  of  the  cord  adds  to 
the  permanence  of  the  cure. 

Direct  Inguinal  Hernia. — It  is  in  direct  hernia  that  we 
find,  in  many  instances,  a  deficiency  of  tissue  with  which  to  make 
a  closure  that  will  permanently  cure  the  case.     It  has  been  my 


236  ABDOMINAL  HERNIA. 

custom  in  operating  upon  direct  hernia  to  carry  out  the  various 
steps  of  the  Bassini  operation  the  same  as  done  in  the  obhque 
variety.  The  sac  protrudes  inside  of  the  cord  (i.e.,  towards 
the  median  Hne)  and  does  not  occupy  the  whole  canal,  but  the 
latter  has  been  opened  in  its  entire  length  the  same  as  in 
oblique  hernia,  the  cord  has  been  lifted  from  its  groove,  and  the 
internal  oblique  closed  beneath  it.     It  has  seemed  to  me  that  in 

Fig.  I20. 


Cord  transferred  to  upper  angle  of  flap  ;  the  latter  passing  beneath  it  is  stitched  to 
the  rectus  muscle. 

this  way,  especially  if  the  internal  oblique  has  been  carefully 
freed  from  its  attachments,  a  better  closure  may  be  made  than 
possible  without  transfer  of  the  cord.  Cases  are  not  uncom- 
monly met  with,  however,  where  the  muscular  structure  of  the 
internal  oblique  and  the  conjoined  tendon  are  so  deficient  that 
it  is  not  possible  to  make  a  strong  barrier  against  the  return  of 
the  hernia  with  them  alone. 

We  then  have  a  choice  of  splitting  its  sheath  and  using  the 
rectus  muscle  (suggested  by  Wofler  in  1892,  Beitriige  z.  Fest- 


SURGICAL  CURE. 


237 


schrift  f.  Th.  BiHrotli,  and  in  1898  in  a  better  form  by  Blood- 
good),  or  what  would  usually  seem  better,  using  the  sheath 
itself  to  close  with  as  suggested  by  Halsted.  In  some  instances 
it  will  be  found  that  the  muscle  can  be  brought  down  without 
undue  tension  and  the  closure  made  strong.  If  any  amount  of 
tension  exists,  however,  the  sutures  are  sure  to  cut  through  its 

Fig.  121. 


Halsted's  method  of  utilizing  the  split  sheath  of  the  rectus  in  closing  the  canal  where  there 
is  deficiency  of  conjoined  tendon. 

fibres  and  the  muscle  will  resume  its  normal  position.  On  the 
other  hand,  by  cutting  a  flap  from  the  sheath  of  the  rectus  it 
can  be  turned  over  and  the  weak  triangle  permanently  fortified. 
This  is  beautifully  illustrated  by  the  plate  made  by  Brodel 
and  reproduced  from  Halsted's  article  already  quoted  (fig. 
121).  I  have  resorted  to  its  use  with  success  where  I  am 
confident  failure  would  have  resulted  from  the  ordinary  opera- 
tion.    This  has  been  done  in  addition  to  bringing  down  all  of 


238  ABDO]\nNAL  HERNIA. 

the  internal  oblique  that  could  be  obtained.  This  method  of 
interlapping  of  the  fascial  layers  is  one  that  has  probably  been 
utilized  by  almost  every  extensive  operator  for  hernia,  both 
before  and  since  the  publication  of  Dr.  Halsted's  article,  but 
the  details  probably  have  not  been  as  carefully  elaborated  any- 
where as  they  ha\e  at  the  Johns  Hopkins  Hospital. 

The  sac  of  a  direct  hernia  is  almost  always  broad  at  its 
base  or  neck,  and  usually  cannot  be  tied  off  with  a  circular 
ligature,  but  must  be  closed  as  a  laparotomy  wound  is,  by 
stitching  its  edges  together.  In  these  cases  it  must  be  con- 
stantly borne  in  mind  that  the  work  is  being  done  in  the  imme- 
diate proximity  of  important  blood  vessels  and  of  the  bladder. 
Two  unpublished  deaths  are  known  to  the  author,  resulting 
from  haemorrhage  into  the  abdominal  cavity  from  vessels 
injured  by  a  needle  used  in  making  this  form  of  closure.  The 
parts  had  in  both  instances  been  closed,  and  there  was  no 
external  evidence  of  the  haemorrhage.  Another  case,  seen  in 
consultation,  where  fortunately  the  haemorrhage  was  external, 
the  patient  was  saved  by  reopening  the  wound  at  once  and 
tying  the  deep  epigastric  arter}'  which  had  been  perforated. 
The  bladder  has  also  been  punctured  in  the  same  manner,  lead- 
ing to  subsequent  extravasation  of  urine. 

In  uncomplicated  cases  of  inguinal  hernia,  if  primary 
union  has  been  obtained,  the  patient  is  allowed  to  sit  up  on  the 
tenth  day,  and  leave  the  hospital  on  the  fourteenth  day  after 
operation ;  the  bandage  is  continued  for  four  weeks  longer 
and  then  all  support  abandoned. 


CHAPTER  XII. 

COMPLICATIONS  IN  THE  SURGICAL  CURE  OF 
INGUINAL  HERNIA. 

Oblique. — In  the  canal  may  1)e  found  fat,  abnormal  ves- 
sels, delayed  testes,  ovaiy,  appendix,  adhesions,  caecum,  sigmoid 
flexure,  and  bladder.  In  operating  for  the  cure  of  inguinal 
hernia  there  are  complications  that  cannot  be  anticipated,  but 
there  are  others  frequently  seen  where  the  operator  should  l^e 
prepared  to  instantly  modify  the  operation  to  meet  the  demands 
of  the  case.  The  disposition  of  surplus  fat  in  the  canal  has 
already  been  spoken  of.  No  loose  fat  should  be  allowed  to 
remain,  either  in  or  near  the  canal,  and  safety  is  always  on  the 
side  of  ligating  it  before  removal,  care  being  taken  not 
to  make  such  traction  upon  that  layer  of  fat  just  outside  of 
the  peritoneum,  as  to  draw  that  membrane  or  a  fold  of  the 
bladder  within  the  ligature.  Remember  that  fat  protruding 
into  the  canal,  near  the  pubic  bone,  may  be  that  covering  the 
anterior  bladder  wall,  of  which  more  will  be  said  later. 

Enlarged  or  varicose  veins  will  be  found  not  only  in  the 
canal  of  the  male,  but  (rarely)  in  the  canal  of  the  female,  and 
these  should  be  carefully  ligated  and  excised.  In  the  male  it 
has  been  pretty  well  established  that  a  fairly  large  number  of 
the  vessels  of  the  cord  can  be  cut  away  without  harming  the 
testicle,  several  writers  claiming  that  if  the  vas  deferens  is  pro- 
tected and  everything  else  divided,  the  testicle  will  still  main- 
tain its  vitality  and  function.  I  must  confess  that  I  have  not 
complete  faith  in  the  power  of  the  very  small  vessels,  that  ac- 
company the  vas,  to  perform  the  full  work  of  the  testicle.  This 
feeling  remains,  even  though  in  the  one  instance  where  I  cut 
away  the  entire  cord  except  the  vas  and  its  closely  associated 
vessels,  no  atrophy  occurred. 

Delayed  Testes. — The  imperfect  descent  of  the  testicle 
forms  one  of  the  rather  common  complications  in  the  surgical 

239 


240 


ABDOMINAL  HERNIA. 


cure  of  hernia.  In  1,205  operations  for  the  cure  of  inguinal 
hernia,  I  found  ^2  cases  where  this  condition  was  associated. 
These  patients  have  been  largely  boys  between  eight  and  sixteen 
years  of  age  (figs.  122,  123,  and  124),  the  youngest  patient 
being  five  and  the  oldest  thirty-five  years  old.  The  operation 
has  not  been  encouraged  in  very  young  children  who  were 
having  no  trouble  from  the  condition,  under  the  belief  that 

Fig.  122. 


Right  retained  testicle  and  complete  inguinal  hernia  in  a  boy  lo  years  old. 

about  the  tenth  year  was  the  most  favorable  time.  It  is  con- 
sidered perfectly  justifiable,  however,  and  to  be  advised  any 
time  after  the  seventh  or  eighth  year,  or  any  time  earlier  when 
demanded  by  the  discomfort  of,  or  danger  to,  the  patient.  In  65 
of  the  y2  cases  it  has  been  possible  to  place  the  testicle  outside 
of  the  abdominal  wall,  and  usually  well  down  in  the  scrotum. 
Not  in  a  single  instance  has  there  been  retraction  of  the  testicle 
into  the  canal  subsequent  to  operation,  so  frequently  com- 
plained of  by  the  earlier  writers.     This  fact  is  considered  due 


COMPLICATIONS  IN  SURGICAL  CURE. 


241 


to  the  extreme  thoroui^lmess  exercised  in  freeing-  the  cord  from 
all  tissues  that  would  restrict  its  descent.      Not  in  anv  instance 


Fig. 


123. 


Boy  9  years  old.     Right  testicle  retained  at  external  ring. 

has  the  testicle  been  anchored  to  the  scrotum  or  other  tissue. 
Care  has  been  taken  to  close  the  external  abdominal  ring  so 

Fig.  124. 


Double  retained  testes;  age,  13  years.     Right  at  internal  ring,  left  at  e.xternal  ring. 
Subsequent  operation  put  both  in  top  of  scrotum. 

closely  around  the  cord  that  the  testicle  could  not  slip  back  into 
the  canal.      In  7  of  these  cases  (all  adults)  the  cord  was  found 
16 


242 


ABDOMINAL  HERNIA. 


permanently  so  shortened  as  to  preclude  the  placing  of  the 
testicle  in  a  comfortable  position  outside  of  the  canal.  That  is, 
if  placed  outside  of  the  external  ring,  it  would  have  been  so 
tightly  held  against  the  pubic  bone  as  to  cause  discomfort  and 
danger  of  injury. 

In  delayed  descent  of  the  testes,  even  though  hernia  is  not 
actually  protruding,  there  is  usually  an  accompanying  sac  suit- 

FlG.   125. 


Showing  sac  around  delayed   testicle,  the    latter   appearing  to  be  inside  of  it.    Sac  held 

open  by  clamps. 

able  for  its  reception.  The  interior  of  such  a  sac  is  illustrated 
in  fig.  125,  and,  as  there  shown,  the  testicle  has  the  appearance 
of  being  inside  the  peritoneum.  This  in  reality  is  not  true  in 
any  case.  The  testicle  may  be  completely  enveloped  by  peri- 
toneum and  hang  free  in  the  abdomen,  the  peritoneum  actually 
forming  a  mesentery  by  which  it  is  supported  and  which,  on  the 
other  hand,  prevents  its  being  placed  in  its  normal  receptacle. 
By  careful  manipulation  the  sac  can  usually  be  separated  from 


COMPLICATIONS  IN  SURGICAL  CURE.         243 

the  cord  at  a  point  near  the  internal  ring,  and  when  it  and  all 
fascia  have  been  cut  through,  the  vessels  of  the  cord  can  be 
further  stripped  away  from  their  attachment  outside  of  the 
peritoneum,  and  thereby  considerably  elongated.  Freeing  the 
cord  of  everything  but  its  essential  elements  is  absolutely  neces- 
sary to  insure  success.  The  neck  of  the  sac  should  Ije  closed 
either  by  ligature  completely  surrounding  it,  or  by  a  purse- 
string  suture  applied  from  its  inside.     The  cord  should  be  free 

Fig.  126. 


Double  retained  testicles,  two  years  after  operation,  placing  them  under  muscular 
wall  and  obliterating  inguinal  canals.  For  photographs  of  this  case  before  operation, 
see  figs.  86  and  87. 

from  every  form  of  adhesion,  so  that  its  vessels  can  be  straight- 
ened out  to  their  greatest  length.  When  this  is  done,  it  will 
almost  always  be  found  that  the  testicle  can  be  placed  in  the 
scrotum. 

Before  this  can  be  done,  however,  a  suitable  pocket  for  its 
reception  must  be  formed  by  running  the  finger  down  into  the 
scrotum  and  forcibly  dilating  it.  When  this  has  been  accom- 
plished, the  testicle  should  be  placed  in  this  pocket  and  the 
operation  may  be  completed  by  the  Bassini  method.     I  have 


244 


ABDOMINAL  HERNIA. 


found  no  child  in  which  this  procedure  could  not  be  carried  out, 
but  in  the  adult  the  problem  is  quite  a  different  one.  In  7  of 
my  adult  cases  there  appeared  to  be  no  way  of  sufficiently 
lengthening  the  cord  so  that  the  testicle  could  be  placed  in  its 
normal  receptacle.  Some  writers  glibly  tell  us  to  remove  these 
testicles,  that  they  are  worthless  and  liable  to  cancerous  or 


Fig.  127. 


Retained  left  testicle  and  irreducible  inguinal  (interstitial)  hernia  ;  age,  24  years.    A  large, 
deep-seated  tumor  (shown  in  fig.  12S),  in  left  inguinal  region,  does  not  show. 

tubercular  affections.  Recent  studies,  however,  show  conclu- 
sively, it  would  seem,  tliat  the  testicle  has  a  function  aside  from 
its  procreative  power,  and  that  this  function  is  beneficial  to  the 
growing  child  or  young  man.  The  well  known  mental  effect 
following  their  removal  is  also  to  be  taken  into  account  before 
sacrificing  one  or  both  of  these  organs.  Furthermore,  it  is  yet 
to  be  proven  that  testicles  lodged  in  the  abdominal  wall  are  any 


COMPLICATIONS  IN  SURGICAL  CURE. 


245 


more  liable  to  malignant  disease  than  when  in  their  normal 
position. 

The  necessity  of  having  some  form  of  operation  that 
would  provide  for  the  saving  of  these  testicles,  where  the  cord 
is  too  short  to  allow  of  their  being  put  in  the  scrotum,  was 
forcibly  brought  home  to  me  in  the  case  shown  in  fig.  126,  two 
years  after  operation.  This  y(^ung  man  demanded  that  unless 
I  could  otherwise  afifdrd  him  relief,  that  both  testicles  should  be 

Fig.  128. 


Case  of  retained  testicle  shown  in  fig.  127.    Whole  sac  and  contents  before  opening. 


removed.  He  was  25  years  old,  had  been  happily  married  for 
two  or  three  years,  and  was  thoroughly  competent  to  discharge 
his  matrimonial  obligations.  He  had  suffered  extremely,  both 
from  the  slipping  of  the  testicles  under  the  truss  pads,  and 
from  attacks  of  strangulated  hernia  whenever  the  truss  was 
left  ofif.  The  amount  of  constriction  by  the  truss,  which 
was  found  necessary  in  order  to  retain  both  the  hernia?  and 
the  testicles,  is  shown  in  the  photograph  (fig.  Sy)  which 
was  taken  upon  the  removal  of  the  truss.      In  entering  upon 


246 


ABDOMINAL  HERNIA. 


this  operation,  I  had  no  very  definite  idea  just  what  I  should 
do,  and  when  I  had  finished  thought  that  I  had  devised  a 
new  operation  for  just  such  cases,  but  found  shortly  after- 
wards that  my  friend,  Prof.  Dawbarn,  had  recommended 
practically  the  same  procedure.  His  operation  had  not  espe- 
cially contemplated  the  relief  of  cases  of  delayed  testes,  but  the 
cure  of  ordinary  inguinal  hernia.^ 

F"iG.  129. 


Sac  with  testicle  inside,  shown  by  dotted  line.    The  location  of  the  cord  is  not  so  distinct 

as  here  indicated. 


Just  how  much  I  may  have  been  influenced  by  this  article, 
or  whether  I  had  even  read  it,  is  now  impossible  for  me  to 
say,  but  of  this  I  am  quite  certain  that  I  did  not  have  it  in 
mind  at  the  time  the  operation  was  performed.  The  procedure 
is  as  follows : 

The  incision  is  made  in  every  respect  as  in  the  Bassini 
operation,  the  aponeurosis  of  the  external  oblique  being  split  to, 
or  above,  the  internal  ring.  The  sac  is  taken  out  completely  (as 
shown  in  figs.  128,  129),  before  opening.     In  some  cases  it  has 


^Transplanting    Testicles    for    the    Cure    of    Hernia,    Robert    H.    M. 
Dawbarn,  M.D.,  Wood's  Reference  Handbook,  Vol.  ix,  p.  415. 


COMPLICATIONS  IN  SURGICAL  CURE.        247 

also  been  possible  to  separate  the  vessels  of  the  cord  and  vas 
from  the  neck  of  the  sac  high  up  before  opening,  and  this,  when 


Fig.  130. 


Retained  testicle,  figs.  127  and  128  ;  sac  opened.    Omentum  in  right  hand,  testicle  within  sac 

in  left  hand. 

it  can  be  accomplished,  is  desirable.  ( In  the  case  shown  in  figs. 
127  and  128,  the  sac  was  full  of  omentum,  which  was  ampu- 
tated and  the  stump  reduced,  leaving  the  testicle  showing  from 

F'iG.  131. 


Sac  cut  away  from  testicle,  ready  to  tie  with  purse-string  suture.    Should  be  closer  to 
peritoneal  surface  than  here  shown. 

the  inside  of  the  sac  as  seen  in  fig.   130.)      The  neck  of  sac 
(really  the  tunica  vaginalis)  must  be  gradually  worked  away 


248 


ABDOMINAL  HERNIA. 


from  the  cord  just  where  the  vessels  leave  it  to  dip  down  into 
the  pelvic  cavity,  and  a  ligature  is  either  passed  around  it,  or  a 
purse-string  suture  is  placed  from  its  inside,  and  it  is  cut  away 
from  the  cord  and  testicle  (figs.  131,  132).  If  it  is  now  decided 
that  the  cord  is  too  short  to  allow  of  the  testicle  being  placed  in 
the  top  of  the  scrotum,  the  fingers  should  be  run  under  the 
internal  oblique  and  transversalis  muscles  towards  the  median 
line,  forming  a  pocket  between  these  structures  and  the  peri- 
toneum (fig.  133).  In  this  pocket  the  testicle  is  then  placed 
and  the  canal  entirely  obliterated  by  closing  it  according  to 

Fig.  132. 


Sac  tied  by  purse-string  suture. 


the  Bassini  method,  except  that  there  is  no  cord  to  provide  for. 
The  closure  can  be  completed,  as  it  is  in  most  cases,  in  the 
female. 

In  the  7  cases  where  I  have  placed  the  testicle  in  this  posi- 
tion, the  patients  have,  in  every  instance,  experienced  the  most 
complete  comfort.  In  one  doubtful  case  on  the  left  side,  I 
found  that  the  testicle  would  come  well  outside  of  abdominal 
wall,  Init  not  fully  into  the  scrotum,  and  I  made  the  mis- 
take of  leaving  it  in  this  position  instead  of  placing  it  under 
the  muscles  as  on  the  otlier  side.  It  has  since  been  a  source 
of  more  or  less  discomfort  to  the  patient.  In  young  chil- 
dren, the  subsequent  and  further  descent  of  the  testicle  can 


COMPLICATIONS  IN  SURGICAL  CURE.         249 


Testicle 


Lifting  up  internal  oblique  and  transversalis  muscles,  to  slip  testicle   into  preformed  pocket 
in  front  of  peritoueum. 


250 


ABDOMINAL  HERNIA. 


be  counted  on,  but  not  so  in  the  adult.  A  photograph  of  the 
first  case  that  I  operated  upon  by  this  method,  two  years  after- 
wards, is  shown  in  fig.  126.  This  operation  was  done  ten 
years  since,  and  the  rehef  and  satisfaction  of  the  patient  has 
been  most  gratifying.  This  is  equally  true  with  every  patient 
upon  wdiom  the  method  has  been  used. 

Fig.  134. 


Interstitial  hernia  and  retained  testicle  on  right  side  in  a  man  of  25  years.  Right  side 
of  scrotum  rudimentary.  Hernial  sac  found  beneath  external  oblique  muscle.  Testicle  inside 
of  external  ring. 


I  wish  it  clearly  understood  that  I  have  not  done,  nor 
found  it  necessary  to  do,  this  operation  of  placing  the  testicle 
between  the  peritoneum  and  the  muscular  wall  of  the  abdomen, 
on  any  young  child,  but  I  am  convinced  that  it  is  far  better 
than  castration,  in  adult  cases.  If  the  testicle  can  be  brought 
down  as  low  as  in  the  case  shown  in  figs.  134  and  135,  it  is 


COMPLICATIONS  IN  SURGICAL  CURE. 


251 


better  to  put  them  in  the  scrotum.  It  is  beheved  that  any 
time  after  the  patient  has  passed  eight  or  ten  years  of  age,  these 
cases  of  delayed  testes  should  be  looked  upon  as  belonging  to 
the  surgeon.  They  always  carry  with  them  an  element  of 
danger  in  the  ever-present  sac  which  frequently  communicates 
with  the  abdomen  by  a  narrow  neck,  making  strangulation 

Fig.  135. 


Same  as  preceding,  three  weeks  after  operation.     Testicle  in  top  of  scrotum. 


especially  liable  and  dangerous.  These  sacs  may  exist  for 
years  without  actual  protrusion  of  intestine,  and  when  it  does 
occur,  a  small  knuckle  of  gut,  strangulated  beneath  the  thick 
muscular  covering,  is  quite  liable  to  be  overlooked  upon  exam- 
ination. The  many  individual  peculiarities  that  have  been  met 
with  in  connection  with  this  class  of  cases,  indicate  their  excep- 
tional danger  in  case  of  strangulation  :  as  adherent  omentum, 


252 


ABDOMINAL  HERNIA. 


adherent  intestine,  and,  in  one  case,  an  adherent  vermiform 
appendix. 

Various  other  operations  have  been  suggested  for  the  rehef 
of  this  condition,  as  suture  of  the  testicle  to  the  bottom  of  the 
scrotum,  or  carrying  the  suture  through  the  bottom  of  the 
scrotum  and  fastening  it  to  a  wire  frame,  of  attaching  the 

Fig.  136 


Sylvia  L.,  aged  7  years.     Double  inguinal  hernia.     Supposed  to  be  a  girl  and  was  so  dressed. 
Operation  demonstrated  double  retained  testes. 


testicle  to  a  flap  from  the  tissues  of  the  thigh,  or  even  attaching 
it  to  its  fellow  of  the  opposite  side.  None"  of  these  methods 
are  given  in  'detail,  as  they  have  not  proven  successful,  but  the 
one  described  has.  One  of  my  cases  of  this  type  is  worthy  of 
mention  somewhat  in  detail,  as  showing  how  analogous  the 
physical  indications  of  sex  may  become  by  certain  tricks  of 
development. 


COMPLICATIONS  IN  SURGICAL  CURE.         253 

Sylvia  L.,  aged  seven  years,  was  apparently  (without  any- 
thing in  a  general  way  to  indicate  that  she  was  not  just  what 
she  was  named  and  dressed  for)  a  girl,  of  rather  large  size 
for  the  age.  Until  recently  the  mother  had  never  doubted  the 
sex  of  her  child,  but  on  consulting  a  physician,  he  found  the 
large  swelling  shown  in  the  photograph  (fig.  136),  and 
detected  two  small  bodies  within  these  swellings  that  he 
believed  to  be  testicles.     When  the  hernize  were  reduced  (fig. 

Fig.  137. 


Sylvia  L.     Herniae  reduced. 

137),  the  external  parts  presented  what  appeared  to  be  the 
normal  vulva  of  a  female  child,  except  that  the  labia  were  some- 
what larger  than  usual.  Upon  separating  the  labia  (fig.  138) 
the  parts  seemed  to  indicate  an  abnormally  large  clitoris  and 
the  entrance  to  the  vagina. 

I  operated  upon  this  child  at  the  Post-Graduate  Hospital, 
curing  its  hernia,  and  at  the  same  time  carefully  examined  the 
pelvic  cavitv,  but,  as  expected,  no  trace  of  uterine  appendages 
were  found.  The  urethra  opened  just  below  the  penis  and  the 
latter,  when  liberated,  would  have  been  nearly  of  normal  size. 


254  ABDOMINAL  HERNIA. 

It  had  been  intended  that  considerable  should  be  done  in 
restoring  him  to  the  sex  that  nature  had  intended  him  to  repre- 
sent, by  various  plastic  operations,  and  with  this  in  view,  the 
testicles  were  left  down  in  what  was  afterwards  to  become  the 
scrotum.  The  penis  was  to  have  been  liberated  and  the  urethra 
brought  out  through  it,  and  then  the  divided  scrotum  was  to 
have  been  united.  The  child  had  Potts'  disease  of  the  spine, 
and  upon  his  recovery  from  the  hernia  operations,  it  was 
deemed  advisable  to  delay  further  surgery  for  at  least  one  year, 
but  before  this  time  arrived,  he  developed  pulmonary  tubercu- 
losis and  died. 

In  1,411  hernia  operations  done  by  the  author,  1,205  h^ve 
been  of  inguinal  type,  and  the  testicle  has  acted  as  a  complica- 
tion as  follows : 

Removed   for  disease :   sarcoma  2,   degeneration   i 3 

Removed  to   save  time  in   operating 2 

Not  found    I 

Found  within  abdomen    (brought  out   i,  left  in   i) 2 

Delayed  descent,  right  side    (put  in  scrotum) 39 

Delayed  descent,  left  side    (put  in   scrotum) 33.  72 

(8  were  both  sides) 

Buried  beneath   abdominal   muscles    (3   sing.,  2  dble.) 7 

87 

Ovary  in  Canal. — It  is  not  very  uncommon,  in  operating 
for  inguinal  hernia  on  the  female,  to  find  an  ovary  in  the  canal. 
As  stated  elsewhere,  when  the  ovary  drops  into  this  posi- 
tion it  is  usually  difficult  to  reduce  without  operation,  and  it  is 
as  persistent  in  attempts  to  slip  under  the  truss  pad,  if  one  is 
being  worn,  as  would  be  a  delayed  testicle  in  the  same  position. 
In  operating,  an  ovary  found  in  the  canal,  if  not  diseased, 
should  be  returned  to  the  cavity  of  the  abdomen  after  it  has 
been  entirely  freed  of  adhesions.  In  two  instances  I  have  been 
obliged  to  remove  them  on  account  of  disease. 

No  case  of  double  descent  of  the  ovaries  has  come  under 
my  personal  observation,  but  a  number  have  been  recorded  by 


COMPLICATIONS  IN  SURGICAL  CURE. 


255 


other  operators.  One  such,  that  is  of  special  interest  on 
account  of  family  history,  is  reported  by  Dr.  William  P. 
Matthews  of  Richmond,  Va.  {"'  Hernia  of  the  Ovary 
Inguinal,"  A'.  Y.  Medical  Record,  Nov.  30,  1901).  A  girl  of 
seventeen,  who  had  double  inguinal  hernia  present  since  birth, 
had  never  menstruated.  Upon  operation  the  ovaries  were 
found  in  the  canals,  and  it  was  ascertained  that  she  had  no 
uterus.     Her  great  grandmother,  twice  married,  bore  children 

Fig.  138. 


Sylvia  L.  Supposed  labia  held  apart,  showing  what  was  thought  to  be  the  clitoris  but 
which  was  really  a  small  penis.  The  urethra  was  immediately  beneath  the  penis,  forming 
what  appeared  to  be  the  vagina. 

by  each  union.  Eight  female  descendants  of  the  first  marriage 
were  never  unwell;  one  of  the  two  daughters  by  the  second 
marriage  was  never  unwell.  Two  aunts  of  the  patient  have 
never  menstruated  and  one  has  double  reducible  inguinal 
hernia.  Five  first  cousins  have  never  menstruated  and  two 
have  double  hernia.  The  patient's  sister  has  never  menstruated 
and  has  double  hernia. 

I  had  a  woman  of  superb  physique  under  my  care  for  many 
years,  for  double  inguinal  hernia,  who  had  never  menstruated 
and  whose  uterus  and  ovaries  were  undiscoverable  and  prob- 


256  ABDOMINAL  HERNIA. 

ably  absent.  She  was  twice  married,  but  never  bore  children. 
Dr.  R.  Ferguson  of  London,  Ontario  ("  Inguinal  Hernia  of  an 
Imperfectly  Developed  Uterus  and  Appendages,"  American 
Medicine,  Sept.  26,  1903),  found  upon  operation  an  incom- 
pletely developed  uterus  and  both  ovaries  in  a  left  inguinal 
hernia  in  a  woman  thirty-two  years  old.  He  ligated  and 
removed  them  completely,  dropping  the  stump  back  into  the 
abdomen,  and  closed  the  canal  by  the  Bassini  method.  Recov- 
er}^ was  prompt  and  relief  complete. 

Dr.  Frank  T.  Andrews  of  Chicago  ("  Hernia  of  the  Tube 
Without  the  Ovary,"  Journal  of  American  Medical  Associa- 
tion, Nov.  25,  1905),  has  in  an  exhaustive  study  of  recorded 
cases  of  the  involvement  of  the  female  pelvic  organs  with 
hernia,  given  the  following  division  of  cases.  He  has  tabu- 
lated 366  cases,  which  are  divided  as  indicated  in  the  fol- 
lowing table : 

"  Hernia  of  Tube  without  Ovary    ,  46  cases. 

Hernia  of  Ovary   and   Tube    80       " 

Hernia  of  Ovary    without    Tube   167       " 

Hernia  of  Non-Gravid  Uterus . . .     43       " 

Hernia  of  Pregnant   Uterus    30       "     ." 

Appendix  Vermiformis  in  Canal. — In  many  instances  the 
appendix  is  held  in  a  position  so  remote  as  to  cause  no  compli- 
cation no  matter  how  large  the  hernia  may  be,  l3ut  in  others 
it  seems  ever  ready  to  drop  into  the  canal  and  become  adherent 
or  otherwise  involved.  The  question  of  the  removal  of  the 
appendix  when  found  with  other  reducible  parts  of  the  hernia 
must  be  decided  by  the  operator,  but  it  has  been  the  author's 
rule  to  remove  them  if  unusually  long;  if  nodular  masses  could 
be  felt  in  its  lumen ;  if  it  showed  the  least  indication  of  former 
inflammatory  conditions. 

In  a  case  recently  operated  upon  there  were  found  adhe- 
sions of  the  omentum,  in  the  vicinity  of  the  internal  ring,  of  an 
inflammatory  character,  that  could  hardly  be  accounted  for  by 
the  presence  of  the  iiernia.      Fxploration  through  the  internal 


COMPLICATIONS  IN  SURGICAL  CURE. 


2.57 


ring  with  the  finger  brought  to  the  surface  a  very  much 
inflamed  appendix,  which  clearly  showed  a  beginning  (jr  a  sub- 
siding appendicitis.     It  is  quite  probable  that  it  was  the  pain  of 

Fig.  139. 


Appendix  adherent  to  posterior  wall  of  hernial  sac,  the  latter  held  open  by  clamps. 

this,  which  was  attributed  by  the  patient  to  his  hernia,  that 
brought  the  case  to  the  operating  table,  and  still  it  might  easily 
have  been  overlooked.     In  a  number  of  cases,  where  there  has 
17 


258  ABDOMINAL  HERNIA. 

been  a  history  of  a  previous  attack  of  appendicitis,  the  appendix 
has  been  brought  out  and  removed  through  the  same  incision 
while  operating  for  hernia.  This  opening  is,  of  course,  not  as 
convenient  as  one  made  especially  for  the  purpose,  but  I  have 
failed  only  once  to  get  it  out  through  the  internal  ring  when  it 
was  wanted,  and,  in  this  instance,  it  was  obtained  by  splitting 
the  internal  oblique  muscle  in  the  direction  of  its  fibre,  just 
above  and  to  the  inner  side  of  the  internal  ring. 

The  method  of  removing  the  appendix  will  usually  be 
governed  by  the  education  and  preference  of  the  operator,  as 
several  excellent  methods  are  taught.  The  author  has  for 
several  years  followed  the  one  of  ligating  and  burying  the 
stump.     The  steps  of  the  proceeding  are : 

(i)  Ligating  the  vessels  of  the  mesentery. 

(2)  Division   of   peritoneal    covering   only,    usually   by    scissors. 

(3)  Tying  in  groove  thus  formed,  with  chromic  gut. 

(4)  Placing  the  burying  suture  of  fine   silk  with  round   needle 

through   peritoneal   coat   of   bowel,   an   inch   away   from 
and  around  insertion  of  appendix  into  caecum. 

(5)  Cutting  off  appendix  and  touching  end  of  stump  with  pure 

carbolic  acid  (  wipe  afterwards  with  alcohol  on  Sponge  ). 

(6)  Depression   of  stump  and  tying  of  burying  suture. 

The  drawing  shown  in  fig.  139  represents  the  condition 
found  in  a  woman  thirty-two  years  of  age.  She  had  noticed  a 
swelling  for  the  past  year  on  the  right  side,  and  it  was  found 
that  considerable  thickening  remained  after  the  reduction  of  the 
bulk  of  the  tumor.  At  the  first  examination  she  was  advised  to 
have  an  operation,  as  it  was  believed  that  either  the  tube  or 
ovary  was  involved.  This  conclusion  was  reached  because  of 
the  fact  that  at  each  menstrual  period  she  had  increased  pain. 
A  truss  was  tried  but  proved  uncomfortable,  and  operative 
relief  was  sought.  On  opening  the  sac  the  condition  shown  in 
the  drawing  was  found.  That  is,  the  appendix  was  found 
lying  along  and  firmly  adherent  to  the  posterior  wall  of  the 
hernial  sac,  and  the  head  of  the  csecum  was  firmly  held  in  the 
internal  abdominal   ring,   the  vessels  of  the  mesentery  lying 


COMPLICATIONS  IN  SURGICAL  CURE. 


259 


between  the  appendix  and  the  sac  surface.     Little  trouble  was 
experienced  in  ligating  them,  freeing  the  head  of  the  caecum, 


Fig.  140. 


■  '/-.:  A<...?'Vj,„„i^--4,'^.,7,j'-i'i;'|V|iil>,V'i-g.^-,  .y^;-'.^-.'j-;'rj  .'-<■■ 


1 


Appendix  adherent  to  anterior  wall  of  hernial  sac,  holding  caecum  in  intern;il  riii.a;      Truss 
worn  over  appendix  for  many  years. 

and  reducing  it  to  the  cavity  of  the  abdomen  after  tying  off  the 
appendix.     The  neck  of  the  sac  was  then  ligated  and  cut  away. 


260 


ABDOMINAL  HERNIA. 


Another  quite  similar  case  is  shown  in  fig.  140.  This 
man  had  been  under  my  care  for  many  years,  and  while 
he  was  obliged  to  wear  an  unusually  strong  truss,  he  suffered 
little  inconvenience  and  was  only  brought  to  the  operation 
through  the  influence  of  friends  who  had  been  cured  of  hernia. 
He  not  only  followed  his  profession  as  a  lawyer,  but  was  an 
all  around  athlete  and  a  long  distance  bicycle  rider.  It  was 
therefore  quite  a  surprise  to  find,  on  operating,  an  appendix 

Fig.  141. 


Top  of  appendix  incarcerated  in  fibrous  ring  in  sac. 


adherent  to  the  anterior  wall  of  the  hernial  sac  in  such  a  posi- 
tion that  his  truss  pad  pressed  directly  across  it  near  its 
junction  with  the  caecum,  and  still  it  showed  no  evidence  of 
inflammation  or  disturbance.  The  adhesions  were  of  a  char- 
acter to  clearly  indicate  that  they  had  been  there  for  many 
years. 

Earlier  in  this  work  reference  has  been  made  to  the  white, 
fibrous  rings  that  form  in  hernial  sacs  and  the  liability  of 
strangulation  to  take  place  in  them.  A  peculiar  illustration  of 
this  is  given  in  the  case  portrayed  in  fig.   141.     This  Avas  a 


COMrLlCATlONS  IN  SURGICAL  CURE.         261 

boy  about  eight  years  old,  nnder  care  at  the  cHnic  for  the  treat- 
ment of  hernia  at  the  New  York  Post-Graduate  Medical  Scliool 
and  Hospital,  but  who  had  not  done  very  well  under  truss 
treatment,  and  as  ciu'e  was  not  anticipated  by  this  means,  he 
was  placed  in  the  hospital  for  operative  cure. 

The  end  of  the  appendix  was  so  firmly  held  within  one  of 
the  rings  above  spoken  of,  that  it  could  not  be  withdrawn,  and 
still  actual  strangulation  did  not  exist.  It  had  the  appearance, 
however,  of  having  been  there  for  a  long  time.  It  was  an 
uncommonly  long  appendix,  probably  fully  seven  inches;  the  tip 
was  down  as  low  as  the  bottom  of  the  "testicle,  and  the  Ccccuni 
was  in  the  upper  part  of  the  canal.  The  Ccccum  was  elongated 
and  merged  so  gradually  into  the  appendix  that  it  was  difficult 
to  decide  just  where  the  latter  Ijegan.  It  is  not  within  my  own 
experience,  but  my  associate,  Dr.  George  E.  Doty,  as  well  as 
several  other  operators,  have  found  the  appendix  in  left  in- 
guinal hernia. 

Adhesions  Within  the  Sac  are  most  commonly  of 
omentum  at  its  sides  or  bottom,  but  it  occasionally  happens 
that  the  intestine  is  adherent,  and  it  then  requires  considerable 
care  and  skill  tO'  avoid  serious  injury.  Attempts  to  tear  such 
adhesions  apart,  unless  they  are  of  the  most  trifling  character, 
should  never  be  made.  A  large  patch  of  the  sac  may,  however, 
be  cut  out  and  left  adhering  to  the  bowel  without  fear  of  harm 
resulting.  Torn  surfaces  upon  the  bowel,  even  though  they 
may  not  endanger  its  integrity,  cause  great  delay  and  incon- 
venience from  the  liability  of  free  oozing  of  blood.  Adhesion 
of  omentum,  if  small  in  area,  can  usually  be  easily  broken  up, 
but  it  is  better  to  tie  them  by  catgut  rather  than  run  anv  risk  of 
subsequent  bleeding'. 

Amputation  of  Omentum  is  worthy  of  especial  discussion, 
both  on  account  of  its  frefpiently  being  required,  and  on  account 
of  the  dangers  attending  its  removal  if  not  carefully  done.  It  is 
much  better  to  remove  large  masses  of  omentum  that  have  been 
outside  the  abdomen  for  some  time,  than  to  attempt  its  replace- 
ment, for  two  reasons : 


262 


ABDOMINAL  HERNIA. 


( I )    It  has  become  shaped  to  the  canal  and  to  the  sac  that 
contains  it,  and  if  crowded  back  into  the  abdominal  cavity, 

Fig.  142. 


Omentum  irreducible  because  of    adhesions.     A,  Omentum.     B,   Neck  of   sac.    C,  Sac  cut 
open      D,  Fundus  of  sac  with  omentum  firmly  adherent. 

remains  in  a  large  mass  at  the  internal  ring  ready  to  again 
dilate  the  canal  and  cause  recurrence  of  the  hernia. 


COMPLICATIONS  IN  SURGICAL  CURE. 


203 


(2)  Omentum  long  resident  outside  of  the  abdomen 
becomes  hypertrophied  and  so  chang-ed  in  character  that  it  may 
act  as  a  foreign  body  when  returned  witliin  the  jjeritoneal 
cavity. 

Formerly  it  was  considered  good  surgery  to  take  a  mass 
of  omentum,  such  as  shown  protruding  through  the  neck  of  the 

Fig.  143. 


Omcuium  spread  out  before  ligating  to  isolate  vessles  and  prevent  risk  of  injuring  intestine. 


sac  in  fig.  142,  pass  a  ligature  around  it  and  cut  it  off.  Work 
of  this  type  was  followed  by  fatal  accidents  from  secondary 
haemorrhage,  and  in  more  than  one  instance,  from  injury  to 
bowel  that  was  lying  unseen  within  the  omentum. 

Many  years  since  I  advocated  a  method  of  ligation  that 
has  become  almost  universally  used  by  careful  surgeons.      It 


264  ABDOMINAL  HERNIA. 

consists  in  drawing  down  the  protruding  mass  until  normal 
omentum  is  brought  outside  of  the  canal,  being  careful  not  to 
make  undue  traction.     It  is  then  spread  out  by  the  hands  (fig. 

Fig.  144. 


Mass  of  omentum  irreducible  from  quantity  and  shape.    Narrow  part  at  top  was  in  the  canal. 

143)  so  that  every  blood  vessel  of  any  considerable  size  can 
be  easily  seen.  Ligation  then  begins  at  one  side  of  this  sheet 
of  omentum  and  progresses  carefully  across  to  the  other.     Fat 


COMPLICATIONS  IN  SURGICAL  CURE.        265 

with  very  small  xessels  is  tied  in  fairly  good  quantity,  but  each 
large  vessel  is  carefully  cleared  of  its  surrounding  fat  and  tied 
off  separately.  No.  2  chromic  catgut  has  been  mcjst  frequently 
used  as  suture  material.  As  many  as  25  ligatures  ha\e  been 
applied  in  removing  a  piece  of  omentum.  After  the  ligatures 
are  in  place  and  the  omentum  is  cut  away,  the  stump,  which 
is  usually  left  about  half  an  inch  long  beyond  the  ligature,  is 
examined  for  any  l^leeding-  points,  and  these  are  also  carefully 
tied. 

Fig.  145. 


Omentum.     Sac  which  contained  it  shown  at  left. 

The  freshly  cut  stump  of  omentum  is  dusted  with  aristol 
and  returned  to  the  abdomen.  The  use  of  the  aristol  may  be 
entirely  unnecessary,  but  it  is  believed  to  prevent  adhesion  of 
intestine  to  the  cut  surface  and  it  has  been  used  by  the  author 
for  many  years. 

Herniae  of  Unusual  Size. — The  large  size  of  hernia  does 
not  in  itself  preclude  its  surgical  cure.  Unfortunately  these 
extreme  cases  occur  most  frequently  in  the  aged  and  infirm, 
and  for  these  reasons  operation  may  be  quite  inadvisable.  If 
the  general  condition  of  the  patient  will  allow  of  it.  the  surgeon 


266 


ABDOMINAL  HERNIA. 


should  feel  it  his  duty  to  give  these  sufferers  not  only  relief,  but 
freedom  from  the  danger  that  is  constantly  with  them  of  acute 
strangulated  hernia;  or  what  is  even  more  fatal,  a  gradual 
paralysis  of  the  protruding  bowel  and  eventual  intestinal 
obstruction. 

Fig.  146. 


Omentum.     At  lower  part  is  the  sac  which  coniained  it. 

It  has  l)een  in  my  experience  a  noticeable  fact,  that  many 
very  large  hernise  are  particularly  easy  to  operate  upon,  and, 
as  a  rule,  the  difficulties  that  will  be  encountered  can  be  fairly 
well  estimated  in  advance,  if  the  following  points  are  carefully 
considered. 


COMPLICATIONS  IN  SURGICAL  CURE.        2G7 

(i)     Is  the  patient's  condition  such  as  to  stand  an  anesthetic 
and  an  operation  of  some  magnitude? 

(2)  Is  the  hernia  reducible  and  is  tlie  cavity  of  the  abdomen 
large  enough  to  receive   it  ? 

(3)  If  not  reducible,  is  it  omentum  or  intestine  that  cannot 
be  reduced? 

The  patient's  actual  age  is  not  nearly  as  important  as  his 
condition;  in  fact,  people  of  advanced  age  usually  stand  the 
operation  well.  If  any  large  portion  is  reducible,  it  is  well  to 
keep  the  patient  in  bed  for  some  days  before  the  operation,  and 
keep  as  much  of  the  hernia  as  possible  within  the  abdomen. 
There  is  little  doubt  that  some  of  these  cases  have  had  a  fatal 
termination,  due  to  extreme  intra-abdominal  pressure  resulting 
from  the  return  of  enormous  masses  of  intestine  and  omentum 
that  have  long  been  outside  of  the  abdominal  cavity.  For  this 
reason  it  is  also  advisable  to  remove  as  much  of  the  protruding 
omentum  as  possible  rather  than  to  replace  it.  I  have  on 
several  occasions  removed  what  appeared  to  be  nearly  the 
entire  omentum  with  no  ill  effects  following.  If,  however, 
upon  examination  it  is  decided  that  the  greater  part  of  a  large 
irreducible  tumor  is  intestine,  and  this  can  usually  be  ascer- 
tained by  percussion  and  general  feeling  of  the  contents,  then 
great  caution  should  be  observed  in  advising  the  operation.  If 
the  intestine  is  extensively  adherent,  the  handling  necessarv  to 
free  it  and  return  it  to  the  abdomen  may,  in  itself,  cause  col- 
lapse of  the  patient. 

Patients  who  have  become  completely  disabled  bv  such 
enormous  herni?e  are  sometimes  willing  to  assume  unusual  risks 
with  the  hope  of  obtaining  relief.  Such  a  case  is  shown  in 
figs.  147  and  148.  This  man  was  seventy-four  years  old,  had 
a  pulse  rate  never  exceeding  50,  and  had  albumen  in  his  urine. 
He  was  told  that  the  risk  of  not  surviving  operation  was 
believed  to  be  fully  one  out  of  five,  and  he  at  once  assured  me 
that  he  had  decided  to  have  the  operation  if  I  thought  he  had 
even  chances  of  living  or  dying.  The  operation  was  done  and 
he  completely  recovered,  and  lived  four  years  more  in  complete 


268 


ABDOMINAL  HERNIA. 


comfort,  so  far  as  his  hernia  was  concerned.  Fig.  149  shows 
him  seven  weeks  after  the  operation,  after  which  time  he  wore 
no  bandage  or  other  support.     One  pecuHar  circumstance  con- 

FiG.  147. 


S.  L.  B.  Age,  74  years.  Operated  upon  Oct.  12,  1899.  Duration  of  hernia,  20  years.  No 
truss  ever  worn.  No  recurrence  to  1903,  when  he  died  of  an  affection  of  heart,  present  when 
operated  upon.  No  support  worn.  Note  that  the  testicle  is  clearly  outlined  at  bottom  of 
scrotum. 


nected  with  this  case  was  that  the  pulse,  which  we  had  been 
unable  to  find  above  50  for  two  weeks  ]:)revious  to  the  operation, 
was  70  on  the  following  morning,  and  did  not  drop  materially 


COMPLICATIONS  IN  SURGICAL  CURE. 


269 


below  this  during-  the  subsequent  eight  or  ten  weeks  that  he 
was  under  observation. 

In  this  case,  in  order  to  aid  in  rapid  work,  the  testicle  and 
sac  were  removed  together  after  hgating  the  cord  separately 

Fig.  148. 


S.  L.  B.  Side  view  of  case  sliown  in  fig.  147. 


at  the  neck  of  the  sac.  The  sac  was  removed  through  the 
inguinal  incision,  the  scrotal  tissues  not  being  touched.  Nor 
was  drainage  of  any  kind  used,  the  wound  being  closed  com- 
pletely and  primary  union  obtained.  If,  however,  there  is  con- 
siderable   oozing    following    the    stripping    out    of    such    an 


270 


ABDOMINAL  HERNIA. 


enormous  sac,  it  is  then  advisable  to  put  a  good-sized  drainage 
tube,  preferably  rubber  with  numerous  fenestra  cut  out,  down 
through  the  bottom  of  the  scrotum.  The  protruding  end  of 
this  tube  should  be  very  carefully  guarded,  by  gauze  moistened 
in  1/2000  corrosive  mercuric  chloride,  and  the  tube  should  be 

Fig.  149. 


S.  L.  B,  seven  weeks  after  operation. 

removed  in  twenty-four,  or,  at  the  outside,  thirty-six  hours.  It 
is  only  by  extreme  care  that  infection  can  be  avoided  where  a 
drainage  tube  is  left  in,  and  it  has  usually  been  my  preference 
to  take  the  risks  of  a  good-sized  hematoma  rather  than  to 
subject  the  patient  to  the  liability  of  infection.  The  blood  clot 
will,  as  a  rule,  be  absorbed  in  the  course  of  three  weeks  and 
does  no  harm.      In  onlv  one  instance  have  I  seen  such  a  clot 


COMPLICATIONS  IN  SURGICAL  CURE. 


271 


become   infected   and   require   evacuation,   and   this  case   was 
unattended  by  symptoms  of  any  importance. 

The  enormous  hernise  now  under  consideration  do  not 
seem  so  hable  to  recurrence  as  would  naturally  be  expected. 
The  case  shown  in  figs.  150,  151,  and  152  is  an  illustration  of 

Fig.  150. 


T.  S.,  50  years  old.  Riglit  inguinal  (scrotal)  hernia  for  20  years;  never  retained.  Measures. 
A  to  B,  14  inches;  circumference,  C  to  D,  2  feet,  2  inches.  Operation  Dec.  4,  1895;  no  recur- 
rence to  1906.  No  truss  worn.  Contents,  large  and  small  intestines,  omentum,  bladder 
inside  of  sac,  and  free  fluid.    Note  right  testicle  at  B,  left  at  Z>.    See  figs.  151,  152. 

this  fact.  The  man  there  shown  was  operated  upon  for  an 
enormous  uncontrollable  scrotal  hernia  and  made  prompt 
recovery,  healing  by  primary  union.  At  that  time  there  was 
no  hernia  on  the  left  side.  Five  years  later  swelling  was 
noticed  on  the  left  side  (fig.  152),  and  I  found  him  with  com- 
plete oblique  hernia  the  size  of  a  hen's  egg,  which  was  operated 


272 


ABDOMINAL  HERNIA. 


upon  and  cured.  Many  experiences  of  this  kind  convince  me 
that  in  these  very  large  hernise  there  is  httle  trouble  in  effecting 
a  permanent  cure. 

In  the  case  shown  in  fig.  153  the  man  was  over  seventy 
years  of  age  and  had  a  hernia  reaching  nearly  to  his  knee,  of 
many  years'  duration,  and  wholly  uncontrollable.     The  hernia, 

F1G.151. 


T.  S.,  six  weeks  after  operation  for  enormous  right  scrotal  hernia.     See  figs.  150,  and  152. 

which  proved  upon  operation  to  contain  mostly  intestine,  both 
large  and  small,  could  be  reduced  to  the  abdomen.  He  was 
kept  in  bed  for  fully  one  week  before  operating,  and  the  hernia 
was  kept  reduced  most  of  that  time  to  accustom  the  abdominal 
cavity  to  its  presence.  The  operation  was  not  particularly 
difficult,  and  plenty  of  good  muscle  was  found  with  which 
to  close  the  very  large  opening. 


COIVirLICATIONS  IN  SURGICAL  CURE. 


273 


Fig.  154  is  a  case  of  very  different  type  and  one,  if  recog- 
nized, where  an  operation  should  not  Ije  attempted.  In  this 
case  it  was  easily  ascertained  that  a  large  amount  of  intestine 
was  present,  a  small  amount  of  it  reducible,  and  it  was  believed 
that  a  large  mass  of  hypertrophied  omentum  was  also  in  the 
sac.     This  unfortunately  did  not  prove  true.     The  man  had 

Fig.  152. 


T.  S.  Recent  left  inguinal  hernia  ;  operation  upon  enormous  right  scrotal  hernia  five  years 
previously.     See  figs.  150  and  151. 

suffered  several  attacks  of  partial  intestinal  obstruction  unac- 
companied by  very  acute  symptoms  of  strangulation,  but 
increasing  in  frequency,  and  the  case  had  every  indica- 
tion that  surgical  relief  was  rec}uired.  The  condition 
observed  upon  operating  was  apparently  a  most  unusual 
one. 
18 


274 


ABDOMINAL  HERNIA. 


On  opening  the  sac  no  omentum  was  found,  on  the  con- 
trary, it  was  packed  with  convolutions  of  bowel  held  on  a 
mesentery  of  very  unusual  character  (fig.  155).  This  mesen- 
tery was  a  fan-shaped,  board-like  mass,  fully  an  inch  thick. 

Fig.  153. 


Enormous  right  scrotal  hernia  in  a  man  over  70  years  old.  Wholly  reducible  but  not  re- 
tainable by  any  truss  that  could  be  tolerated.  Contents,  large  and  small  intestine  and  small 
amount  of  omentum. 


having  a  feeling  somewhat  like  that  of  a  dense,  broad  tendon. 
At  the  point  where  it  entered  the  abdomen,  it  was  bunched 
together  into  a  mass  as  large  as  an  adult  forearm,  just  below 
the  elbow,  and  apparently  almost  as  inflexible. 


COMPLICATIONS  IN  SURGICAL  CURE. 


275 


Those  who  have  operated  upon  large  hernicC  will  fully 
realize  the  almost  insurmountable  difficulties  of  the  situation. 
The  entire  mass  was  finally  returned  to  the  abdominal  cax'ity 
and  the  wound  closed,  but  the  patient  did  not  long  survive  the 
operation.  The  feeling  of  the  tumor,  which  led  to  the  belief 
that  it  contained  a  large  mass  of  omentum,  was  really  produced 

Fig.  154. 


M.  G.,  40  years  of  age.     Irreducible  left  scrotal  hernia  packed  with  intestine  on  peculiar 
hypertrophied  mesentery.     Duration,  20  years.     Never  retained. 


by  this  peculiar  hypertrophied  (if  it  may  be  so  called)  mesen- 
tery. The  ultimate  termination  of  this  case,  if  it  had  not  been 
operated  upon,  would  in  all  probability  have  been  by  intestinal 
obstruction  produced  by  gradual  loss  of  peristalsis  in  the  pro- 
truding bowel.  I  have  seen  only  one  other  case  at  all  similar, 
nor  do  I  recall  having  seen  mention  of  any  like  it  by  other 
operators. 


276 


ABDOMINAL  HERNIA. 


]\Iy  other  case  was  in  a  woman  with  enormous  femoral 
hernia  shown  in  the  photograph,  fig.  169,  and  even  this  did  not 

Fig.  155. 


Intestine  which  was  irreducible  on  account  of  hypertrophy  and  hardening  of  its  mesentery. 

present  the  extreme  difficulties  met  with   in  the  case  under 
consideration. 


CHAPTER  XIII. 
SIGMOID,  C^CAL,  AND  BLADDER  HERNIA. 

Hernise  of  the  sigmoid,  caecum,  and  bladder,  belong  to  the 
direct  type  of  inguinal  hernia  and  are  classed  together  because 
of  similar  anatomical  peculiarities.  In  the  accidents  which 
may  occur  during  the  operation  for  their  cure  they  are  also 
similar. 

In  the  chapter  on  diagnosis  will  be  found  suggestions 
which  may,  in  some  instances  at  least,  lead  to  the  recognition 
of  sigmoid  and  csecal  hernia  before  the  operation;  in  many 
others,  how^ever,  there  are  no  distinguishing  signs  previous  to 
the  opening  of  the  parts,  and  even  then  serious  mistakes  may  be 
made.  It  is  perhaps  wise  to  look  upon  all  direct  herni^e  as 
extra-hazardous  and  to  use  extraordinary  care  in  operating 
upon  them.  Petit  (Rechcrches  siir  les  causes  des  hernies)  has 
truly  said  that  hernial  sacs  are  full  of  deception. 

My  own  experience  leads  me  to  feel  that  sigmoid  and 
csecal  hernia  can  usually  be  recognized,  or  at  least  suspected, 
before  operation  by  their  peculiar  form  (see  photographs  of 
cases),  their  slowness  of  reduction,  especially  of  the  last  part  of 
the  tumor,  and  by  the  fact  that  not  only  are  they  frequently 
uncontrollable  by  truss  pressure,  but  the  wearing  of  any 
mechanical  support  is  intolerable  because  of  the  pain  produced. 

The  difficulties  in  operating  upon  hernise  of  the  direct 
type,  especially  the  three  forms  now  under  consideration,  are 
largely  due  to  the  distribution  of  the  peritoneum.  The  pro- 
trusion takes  place  at  a  point  where  the  peritoneum  leaves  the 
abdominal  wall  and  is  reflected  over  the  pelvic  organs,  \\nien 
it  is  carried  through  the  abdominal  wall  it  drags,  by  its  at- 
tachments to  them,  one  of  these  organs  with  it.  This  is  espe- 
cially true  of  the  large  bowel  on  either  side  and  the  bladder, 
on  account  of  their  being  freely  movable  and  conveniently 

277 


278 


ABDOMINAL  HERNIA. 


placed.  While  the  peritoneum  completely  surrounds  the  small 
and  in  some  parts  the  large  intestine  it  covers  only  the  anterior 
surface  of  both  the  sigmoid  flexure  and  caecum.  It  is  for  this 
reason  that  a  portion  of  the  large  bowel  on  either  side  may 
protrude  without  a  hernial  sac,  and  if  not  recognized  by  the 
operator  may  be  opened  by  mistake.  Tuffier  (Etude  siir  le 
ccncimi  et  les  hernies,  Arch  Gen.  de  Med.,  7th  ser.,  vol.  xix,  p. 
642)  found  in  the  examination  of  100  bodies  that  9  per  cent, 
had  the  posterior  surface  of  the  cscum  uncovered  by  peri- 

FiG.  156. 


Sac  wall 


Hernial  sac  containing:  fiee  caecum  and  loops  of  small  intestine. 


toneum.  The  bladder  is  covered  by  peritoneum  upon  its 
summit  and  a  small  portion  of  its  posterior  wall,  but  not  its 
anterior  wall. 

\\'hen  this  distribution  of  peritoneum  is  considered  it  will 
be  readily  understood  how  any  one  of  these  organs  may  pro- 
trude in  either  one  of  three  conditions  :  ( i )  It  may  become  a 
part  of  the  hernial  contents,  in  a  preformed  sac — intra-peri- 
toneal  (fig.  156).  (2)  It  may  protrude  independently,  with- 
out any  serous  covering — extra-peritoneal  (fig.  157).  (3)  It 
may  be  dragged  down  in  the  formation  of  the  hernial  sac  and 


SIGMOID:  CiECAL:  BLADDER. 


279 


have  a  partial  peritoneal  covering,  and  become  both  intra-  and 
extra-peritoneal. 

As  previously  stated,  protrusions  into  a  preformed  sac 
ha^'e  not  been  considered  by  the  author  to  constitute  either 
sigmoid,  czccal,  or  bladder  hernia,  because  they  are  easily 
reduced  with  the  other  hernial  contents,  quickly  recogiiized, 
and  not  liable  to  accidental  injury. 

Sigmoid  and  Cascal  Hernia. — In  these  hernise  the  bowel 
may  be   dragged   down   by   a   sac   of  peritoneum   previously 

Fig.  157. 


Sac  wall 


Hernial  sac  in  front  of  caecum.    No  peritoneal  covering  on  posterior  wall  of  bowel. 


formed  and  containing  other  folds  of  the  large,  or  many  loops 
of  small  intestine  and  omentum.  The  posterior  sac  wall  is  then 
the  normal  peritoneal  covering  of  the  anterior  surface  of  either 
the  caecum  or  sigmoid,  as  the  case  may  be.  If  the  operator, 
fortunately,  opens  into  the  sac  high  up,  near  the  internal  ring, 
he  will  usually  discover  the  true  state  of  affairs  and  avoid 
injury  to  the  bowel,  either  by  tying  off  a  portion  of  it  with  his 
sac  ligature,  or  bv  rudely  tearing  it  away  from  its  deep  attach- 
ments and  perhaps  lacerating  the  intestinal  wall  in  a  manner 
that  would  be  difficult  to  repair.     If,  on  the  contrary,  he  opens 


280  ABDOMINAL  HERNIA. 

into  the  fundus  or  lower  portion  of  such  a  protrusion  he  may 
discover  too  late  that  he  has  opened  directly  into  the  bowel. 

In  operating  upon  these  extremely  difficult  cases  unusual 
caution  is  necessary  throughout  the  entire  operation :  ( i )  In 
the  opening  of  the  sac.  (2)  In  separating  the  fleshy  attach- 
ments of  the  bowel  from  the  deep  parts.  (3)  In  the  closure 
of  the  sac.  (4)  In  the  closure  of  the  enonnously  large  open- 
ing which  is  left  in  the  muscular  wall  of  the  abdomen  after  the 
reduction  of  the  bowel. 

In  opening  down  upon  any  sac  of  the  direct  type,  with 
broad  base,  it  should  be  the  invariable  rule  to  separate  the 
extra-peritoneal  fascia  well  up  towards  the  internal  ring,  pick 
up  the  peritoneum  where  it  is  thin  and  free,  and  open  it  care- 
fully between  anatomical  forceps.  If  this  one  precaution  were 
strictly  adhered  to  it  would  prevent  most  of  the  accidental 
openings  of  the  bladder  and  large  bowel.  Had  I  adhered  to 
this  point,  which  I  have  carefully  taught  my  classes  at  the  New 
York  Post-Graduate  Medical  School  and  Hospital  for  many 
years,  I  would  have  avoided  my  only,  but  nevertheless  mortify- 
ing, mistake  of  opening  into  the  bladder.  In  this  case  I  was 
so  certain  that  I  was  dealing  with  a  true  hernial  sac  that  I 
opened  it  even  while  speaking  of  the  liability  of  bladder  acci- 
dents in  hernia  operations. 

When  the  peritoneal  cavity  has  been  entered  near  the 
internal  ring,  the  finger  can  be  passed  down  into  the  fundus 
of  the  sac,  if  present,  or  it  can  be  ascertained  that  the  protrusion 
is  actually  extra-peritoneal,  and  it  can  be  dealt  with  accord- 
ingly. If  the  sac  cannot  be  readily  lifted  from  its  posterior 
attachments  it  should  be  suspected  at  once  that  it  is  either 
sigmoid,  caecal,  or  bladder  hernia.  When  the  finger  is  within 
the  peritoneum,  the  anterior  sac  wall  may  then  be  carefully  cut 
upon  it  with  l)lunt  scissors,  care  being  exercised  to  avoid 
intestinal  adhesions  that  may  be  present,  and  remembering  the 
immediate  proximity  of  the  epigastric  artery.  The  contents  of 
the  sac  may  then  be  freely  examined  and  so  far  as  possible 
reduced. 


SIGMOID:  C/ECAL:  BLADDER. 


281 


The  second  step  in  the  operation  is  to  separate  the 
posterior  wall  of  the  bowel  from  its  attachment.  This  may  be 
(lone  bv  gently  pushing-  the  fingers  upwards  between  the  bowel 
and  the  deeper  parts,  exerting  as  little  force  upon  the  intestine 
as  possible,  and  watching  closely  for  broken  vessels,  which 
should  be  tied  at  once  even  though  small.  The  point  of  separa- 

FlG.   158. 


Form  of  purse-string  suture  for  sigmoid  sac. 

tion  between  the  structures  should  be  carried  well  up  into  the 
abdomen  so  that  the  bowel  can  be  reduced  wdth  perfect  free- 
dom. It  is  necessary  to  exercise  caution  in  pushing  the  bowel 
back  not  to  telescope  it  into  itself,  thereby  producing  an  intus- 
susception. 

Closure  of  the  Sac  ('fig.  158). — It  is  quite  obvious  that  a 
sac  of  this  type  cannot  be  closed  by  an  ordinarv  ligature,  as 
its  posterior  wall  is  formed  of  bowel.     It  is  best  done  bv  a 


282 


ABDOMINAL  HERNLi. 


purse-string  suture  applied  from  the  inside  of  the  sac,  going 
well  up  to  the  internal  ring,  or  peritoneal  surface  on  its 
anterior  wall,  and  approaching  with  caution  that  part  attached 
to  the  bowel.  AMien  this  suture  (usually  no.  2  plain  catgut 
used  double)  is  tied,  the  sac  is  perforated,  and  any  surplus  of 
sac  wall  that  exists  is  drawn  up  and  ligated  outside  the  purse- 
string  suture  and  cut  away.     The  ends  of  the  sac  ligature  with 

Fig.   159. 


Lifting  internal  oblique  muscle  to  burj-  stump  of  sac  beneath  it. 


needle  attached  are  used  to  anchor  the  stump  of  the  sac,  with 
attached  bowel,  in  the  following  manner : 

The  internal  oblique  and  transversalis  muscles  are  sepa- 
rated from  the  peritoneum  by  slipping  the  ends  of  the  fingers 
between  them  and  the  peritoneum,  above  the  internal  ring  and 
towards  the  median  line  (fig.  159).  The  needle  on  the  sac 
stump  ligature  is  passed  through  these  muscles  from  within 
outwards,  and  then  back  at  another  point,     ^^'hen  it  is  tied 


SIGMOID:  C^CAL:  BLADDER.  283 

with  the  free  end  of  the  stump  ligature  it  will  invert  the  sac 
stump  and  carry  the  attached  bowel  well  away  from  the 
inguinal  canal.  I  am  convinced  that  the  anchoring  of  this 
elongated  loop  of  bowel  well  away  from  the  internal  ring  is  a 
great  aid  in  the  prevention  of  recurrence. 

The  details  of  the  closure  of  these  large  openings  in  the 
abdominal  wall  must  depend  upon  the  condition  of  the  sur- 
rounding muscular  tissue  and  the  preference  of  the  operator. 
The  first  essential  of  success  is  thorough  and  careful  work 
whatever  technique  is  adopted.  If  there  is  an  abundance  of 
good  muscular  tissue  it  has  been  my  habit  to  close  exactly  as 
in  oblique  inguinal  hernia.  Even  though  the  neck  of  the  sac 
is  at  the  external  ring  and  the  upper  canal  unoccupied,  it  is 
important  that  the  cord  should  be  displaced  at  its  junction 
with  the  peritoneum,  the  lower  edges  of  the  internal  oblique 
and  transversalis  muscles  wrapped  closely  around  it,  and 
stitched  to  Poupart's  ligament  throughout  the  length  of  the 
canal.  The  continuous  suture  of  the  peculiar  type  already 
shown  (figs.  Ill,  112),  is  believed  to  make  a  more  accurate 
closure  than  is  possible  with  the  interrupted.  Especial  care  is 
taken  in  these  cases  to  see  that  the  closure  is  made  as  per- 
fect as  possible  in  the  aponeurotic,  as  well  as  in  the  muscular 
structures. 

In  some  of  these  cases  the  method  of  overlapping,  already 
mentioned,  has  been  used  with  advantage,  and  in  one  the 
rectus  was  split  and  turned  out  in  order  to  get  sufficient  tissue 
to  make  a  firm  closure.  Even  where  ever}-  precaution  is 
taken  there  is  little  doubt  that  sigmoid  and  cjecal  hernia  will 
furnish  a  larger  percentage  of  recurrences  than  herni?e  of  the 
oblique  inguinal  type.  In  view  of  this  fact  it  is  advisable  to 
keep  them  under  closer  scrutiny  after  operation,  and,  if  anv 
sign  of  weakness  of  the  abdominal  wall  is  discovered,  to  place 
a  support  upon  them  before  actual  protrusion  occurs.  At  this 
time  a  good  abdominal  belt,  that  gives  support  over  the  whole 
lower  part  of  the  abdomen,  is  usually  better  than  a  regular 
truss,  and  should  be  worn  with  less  discomfort. 


284  ABDOMINAL  HERNIA. 

Bladder  Hernia. — Like  tlie  hernias  just  discussed,  the 
bladder  may  protrude  through  the  abdominal  wall,  either  inside 
of  a  true  hernial  sac  without  any  peritoneal  covering,  or  with 
both  conditions  present.  Little  attention  has  been  given  to 
those  cases  where  the  bladder  protrudes  within  the  sac  covered 
by  peritoneum,  as  there  is  no  liability  of  accidental  injury,  and 
it  is  easily  reduced  with  the  rest  of  the  hernial  contents. 

In  1895  Dr.  B.  Farquhar  Curtis  made  a  most  valuable 
contribution  to  this  subject  (''Wounds  of  the  Bladder  in 
Operations  for  Hernia,"  Aiinols  of  Surgery,  June,  1895).  In 
this  study  of  the  subject  he  collected  41  cases  in  which  the 
bladder  was  wounded  during  operation,  and  1 7  in  which  it  was 
recognized  and  returned  without  injury.  Only  two  years  later 
Dr.  C.  L.  Gibson  ("  Personal  Experience  in  Hernia  of  the 
Bladder,"  Med.  Record,  March  20,  1897)  collected  and  added 
45  cases  to  the  list  of  Curtis,  making  a  total  of  103  cases.  The 
report  of  Curtis's  58  cases  covered  the  dates  from  1575  to 
1895  (300  years),  while  Gibson's  45  cases,  with  three  excep- 
tions, included  onty  those  reported  during  the  two  subsequent 
years.  In  those  two  years  there  had  been  nearly  as  many 
reported  as  had  appeared  in  all  previous  literature. 

In  the  combined  cases  of  Curtis  and  Gibson  there  were  76 
males  and  23  females;  70  males  and  7  females  had  inguinal 
hernia;  16  males  and  16  females  had  femoral  hernia.  ]\Iore 
than  half  of  the  cases  (52)  were  over  fifty  years  of  age,  the 
voungest  being  two  and  one-half  years.  The  bladder  was 
intra-peritoneal  in  7,  and  extra-peritoneal  in  yT)  instances;  18 
were  both  intra-  and  extra-peritoneal. 

,  Undoubtedly  the  most  dangerous  and  deceptive,  as  well 
as  the  most  common,  variety  is  tlie  extra-peritoneal,  which 
comes  through  the  abdominal  wall  uncovered  by  peritoneum. 
Frequently  it  constitutes  the  entire  hernia  and  the  surgeon  is 
verA-  apt  to  mistake  it  for  the  hernial  sac.  These  bladder  pro- 
trusions may  vary  in  size  from  that  of  the  end  of  one's  finger 
to  the  entire  bladder.  The  entire  bladder  and  prostate  gland 
have  been  found  in  a  hernial  protrusion  of  this  type.     The 


SIGMOID:  CiECAL:  BLADDER.  28.5 

bladder  protruding  in  this  position  has  been  mistaken  for 
hernial  sac,  lipoma,  properitoneal  fat,  omentum,  cyst,  thickened 
patch  in  hernial  sac,  hydrocele  of  the  cord,  sacculation  of  the 
colon,  or  a  second  hernial  sac.  Plummer  thinks  that  it  would 
be  particularly  liable  to  be  found  in  recurrent  herni^e,  as  the 
first  operation  would  be  apt  to  draw  it  toward  this  point. 

Bladder  w^ounds  accidentally  inflicted,  during  operations 
for  the  relief  of  hernia,  have  become  too  common  to  be  longer 
considered  surgical  curiosities.  This  fact  does  not  indicate 
increasing  carelessness  on  the  part  of  the  surgeon,  nor  does  it 
lessen  the  importance  of  the  subject.  It  is  unquestionably  due 
to  the  greatly  increased  number  of  hernia  operations  being  per- 
formed, and  to  the  apparent  impossibility  of  always  being  able 
to  distinguish  between  the  hernial  sac  and  the  bladder  wall.  It 
is  to  be  hoped,  and  it  is  probable,  that,  as  many  operators  are 
led  to  study  it  more  closely,  valuable  knowledge  will  accumulate 
which  will  afford  greater  protection  against  this  accident. 

The  diagnosis  of  bladder  hernia  is  seldom  made  before 
operation,  but  as  more  attention  is  given  to  the  subject  there 
will  be  more  cases  that  will  be  at  least  considered  suspicious. 
In  fact,  the  only  safe  method  is  to  consider  all  cases  of  direct 
hernia,  or  hernia  in  very  fat  patients,  as  being  a  possible 
bladder  hernia ;  if  on  guard  the  operator  will  usually  recognize 
the  condition,  if  present.  The  indications  may  be  divided  into 
those  to  be  looked  for  before,  and  those  met  with  during, 
operation. 

Before  Operation. — The  history  of  any  bladder  symptom 
that  can  be  obtained  from  the  patient  should  be  considered 
suspicious.  In  the  case  shown  in  the  photographs  (figs.  150 
and  151  )  the  patient  informed  me  that  while  urinating  he  was 
usually  obliged  tO'  compress  the  scrotal  protrusion  with  both 
hands.  At  the  operation  a  large  protrusion  of  bladder  wall 
was  found  (intra-peritoneal)  protruding  into  the  hernial  sac. 
This  was  reduced  as  easily  as  the  omentum  and  intestine  that 
also  occupied  the  sac  in  large  quantities.  After  the  operation, 
however,  he  was  unable  to  void  his  urine,  and  it  was  then  dis- 


286  ABDOMINAL  HERNIA. 

covered  that  it  was  impossible  to  pass  a  catlieter.  Perineal 
section  became  necessary  two  days  later.  He  obtained  primary 
union  in  the  hernia  wound  and  made  a  rapid  recover3^ 

Pressure  upon  the  tumor  may  in  some  cases  cause  a  desire 
to  urinate.  This  was  strikingly  demonstrated  in  one  of  my 
cases  where  the  bladder  was  found  involved  at  the  time  of 
operation.  Dr.  J.  F.  Baldwin  ("  Hernia  of  the  Bladder," 
Complete  Inguinal  Extra-peritoneal.  Recovery.  Am.  Med. 
J  our.,  May  i8,  1901)  reports  a  case,  of  eight  years'  duration, 
in  a  man  of  fifty-one  years,  where  the  bladder  was  protruding 
to  the  size  of  two  fists.  Ordinarily  this  swelling  was  reducible, 
but  for  forty-eight  hours  before  operation  it  could  not  be 
reduced.  The  previous  history  showed  that  the  patient  was 
obliged  to  lift  the  tumor  every  time  he  urinated,  and  the  pro- 
trusion had  been  uncontrollable  by  a  truss. 

The  slowness  of  the  reduction  of  these  tumors,  and  in 
some  its  apparent  incompleteness,  should  lead  us  to  suspect  that 
we  have  either  large  bowel  or  bla.dder  to  deal  with.  It  has 
been  suggested  that  there  may  also^  be  felt  a  rush  of  fluid  when 
quick  and  firm  pressure  is  made.  This,  however,  seems  to  the 
author  a  somewhat  misleading  suggestion,  as  many  large 
hernial  sacs  contain  fluid  in  appreciable  quantities  when  no 
bladder  protrusion  is  present.  Furthermore,  it  is  not  in  hernise 
of  enomous  size  that  we  are  liable  to  mistake,  but  rather  in 
small  or  medium-sized  hernise  of  the  direct  type  with  no 
suspicious  symptoms. 

Dr.  S.  C.  Plummer  ("Inguinal  Hernia  of  the  Bladder," 
Jour.  A.  M.  A.,  July  22,  1905)  suggests  that  a  test  be  made 
of  having  the  patient  retain  his  urine  for  a  long  time  to  see  if  it 
influences  the  tumor.  The  passing  of  a  sound  has,  in  some 
instances,  verified  the  suspicion  of  bladder  hernia,  but  in  others 
it  has  failed.  At  the  time  of  operation  this  has  proved  of  great 
service  to  me,  and  has  in  several  cases  enabled  me  to  decide  that 
I  was  dealing  witli  the  l:)ladder  wall. 

Indications  at  Operation. — On  opening  into  the  canal  a  sac 
found  protruding  at  the  inner  side  of  the  cord,  close  to  the 


SIGMOID:  C^CAL:  BLADDER. 


287 


pubic  bone,  should  cause  us  to  proceed  with  caution.  This  is 
especially  true  where  it  seems  deeply  imbedded  in  fat  from 
which  it  is  hard  to  separate  it,  and  where  it  has  a  broad  base. 


Fig.  i6o. 


Showing  a  protrusion,  the  upoer  half  of  which  was  peritoneal  sac  containing  intestine, 
the  lower  half,  bladder.  The  dividing  line  has  been  intentionally  exaggerated.  In  the  patient 
it  did  not  show  so  clearly. 

One  would  think  that  the  bladder  wall  could  be  recognized 
by  its  muscular  covering,  but  this,  in  my  experience,  cannot 


288  ABDOMINAL  HERNIA. 

be  relied  upon.  This  difficulty  is  well  illustrated  by  the  case 
reported  by  Dr.  Rudolph  Winsboro  ("  Direct  Inguinal 
Hernia,"  Injury  to  Bladder,  Virginia  Medical  Scmi-Monthly, 
Feb.  lo,  1904).  He  says  :  "  To  the  inner  side  of  the  sac  was 
a  mass  separated  with  great  difficulty  .  .  .  about  the  cord  was 
a  translucent  area  which  evidently  contained  fluid."  Think- 
ing it  an  encysted  hydrocele,  he  incised  it  and  at  once  recog- 
nized urine  by  its  odor.  McLachlan  states  {Applied  Anatomy, 
vol.  ii,  p.  469)  that  "  in  sacculated  bladder  the  walls  of  the 
sacculi  contain  no  muscular  fibres.  The  mucus  membrane  is 
forced  through  the  bundles  of  muscular  fibres,  forming  sac- 
culi." 

When,  on  pulling  up  an  inguinal  sac,  there  appears  in  its 
neck  a  mass  of  fat  covered  by  peritoneum,  it  is  highly  im- 
portant that  it  be  neither  ligated  with  the  sac  nor  punctured 
with  a  needle,  as  it  is  in  all  probability  bladder.  This  is 
most  likely  to  occur  in  direct  hernia,  but  I  have  also  seen  it  in 
the  oblique  variety.  When  two  sacs  are  present  in  the  canal 
it  is  safe  to  conclude  that  one  is  bladder. 

It  has  been  stated  that  bladder  wall  is  difficult  to  separate 
from  the  surrounding  fat,  and  this,  it  is  believed,  is  true.  In 
my  own  case,  w^hen  I  committed  the  error  of  opening  into  the 
bladder,  it  was  very  readily  lifted  from  the  mass  of  fat  which 
surrounded  \i  and  there  was  no  true  hernial  sac.  In  the  case 
shown  in  fig.  160,  where  the  upper  half  of  the  tumor  was 
hernial  sac  and  its  lower  half  bladder,  the  latter  came  out  of 
the  canal  as  easily  as  the  former.  The  first  appearance  of  the 
bladder  part  of  the  tumor  was  of  loose  fat  in  the  canal.  When 
this  fat  was  lifted  out,  the  bulging  above,  which  proved  to  be 
the  true  sac,  was  brought  to  view.  From  the  opening  made  in 
the  latter  it  was  easily  demonstrated  that  the  lower  part  was 
bladder.  The  sac  was  closed  by  purse-string  suture,  the  l^ladder 
protrusion  was  inverted  into  itself  and  the  muscular  wall  care- 
fully closed.  In  the  case  shown  in  fig.  161  the  liability  to  mis- 
take is  in  supposing  that  the  lower  protrusion  is  of  an  ordinary 
direct  hernia.     It  is  entirely  possible  to  have  oblique  and  direct 


SIGMOID:  CECAL:  BLADDER. 


289 


hernia  on  the  same  side,  and  their  true  character  can  be  quickly 
ascertained  by  opening  the  upper  sac  and  exploring  the  lower 
one  through  this  opening. 


Fig.  ]6i. 


Hernial  sac  above,  and  bladder  iirotrusion  (extraperitoneal)  below,  in  man  60  years  of  age. 


In  bladder  as  well  as  in  sigmoid  and  c?ecal  hernia  many 
uncertainties  in  diagnosis,  and  a  great  many  operative  diffi- 
culties, are  avoided  by  opening  into  the  sac  or  peritoneal  cavity 

19 


290  ABDOMINAL  HERNIA. 

well  up  toward  the  internal  ring.  The  bladder,  the  caecum 
and  the  sigmoid  are  thus  avoided,  as  well  as  the  confusion  that 
sometimes  comes  to  an  inexperienced  operator  by  opening  into 
an  unobliterated  tunica  vaginalis.  It  must  be  borne  in  mind 
that  in  double  hernia  the  bladder  may  protrude  on  both  sides. 
Gibson  reports  such  a  case  and  I  have  had  one  recently  in  a 
young  man  under  thirty,  ^^'hen  the  bladder  has  been  recog- 
nized before  opening,  it  has  been  gently  separated  from  its 
abdominal  adhesions  and  pushed  back  into  place,  and  the 
muscular' wall  very  accurately  closed  over  it.  In  one  instance 
I  turned  the  sacculated  part  into  the  bladder  by  inversion,  get- 
ting it  entirelv  away  from  the  canal. 

Repair  of  Bladder  Wounds. — An  accident  that  has  hap- 
pened so  many  times  and  to  so  many  dift'erent  operators  will 
certainly  happen  again  and  it  is  advisable,  therefore,  that  those 
who  contemplate  doing  the  operation  for  the  cure  of  hernia 
should  have  definite  ideas  as  to  what  they  will  do  when  con- 
fronted by  a  bladder  accidentally  opened. 

On  certain  points  in  the  repair  of  bladder  wounds  there 
are  no  differences  of  opinion,  but  on  others,  operators  of  experi- 
ence difi'er  widely.  The  merest  tyro  in  medicine  under- 
stands— for  it  is  one  of  the  earliest  teachings  in  surgery — that 
in  closing  a  bladder  wound  its  walls  must  not  be  stitched 
through  and  through.  Able  operators  also  agree  that  such 
wounds  are  best  closed  by  layers  of  sutures,  some  advising  two, 
others  three  overlying  rows.  Some  advise  that  the  mucous 
membrane  lining  the  bladder  shall  be  first  closed  by  small,  plain 
catgut,  and  then  the  muscular  and  serous  coats  brought 
together  above  this  by  two  more  rows  of  silk  or  catgut ;  others 
prefer  to  put  no  sutures  in  the  mucous  membrane,  relying 
entirelv  upon  the  muscular  closure  to  prevent  leakage.  It 
seems  rational  that  tlie  use  of  small-size  plain  catgut  to  close 
accurately  the  mucosa  adds  materially  to  the  protection  against 
leakage,  and,  owing  to  its  early  absorption,  subjects  the  patient 
to  little  risk  of  having  concretions  form  upon  it  within  the 
bladder.  It  is  certain  that  silk  should  never  be  used  for  this  laver. 


SIGMOID:  CiECAL:  BLADDER.  201 

The  tendency  of  late  writers  upon  the  subject  is  in  favor 
of  catgut  throughout  the  operation.  Curtis  says  on  this  point : 
"  Whether  silk  or  fine  catgut  is  employed  seems  tO'  be  a  matter 
of  indifference,  but  the  sutures  should  ncjt  penetrate  the  mucfjus 
membrane;  they  should  be  placed  very  close  together,  ten  or 
twelve  to  the  inch,  and  there  should  be  at  least  two  layers,  and 
by  preference  three."  Dr.  Orville  Horwitz  (Annals  of  Sur- 
gery, December,  1905)  expresses  the  following  positive  opin- 
ion on  this  subject :  "  It  is  generally  conceded  that  the  wound 
is  best  closed  with  fine  silk,  as  the  catgut  sutures  cannot  be 
depended  upon  to  endure  for  a  sufficient  length  of  time.  Sev- 
eral cases  have  been  reported  in  which  this  latter  material  was 
employed  where  a  leakage  occurred,  owing  to  a  too  rapid 
absorption  of  the  suture,  death  resulting  from  peritonitis." 
Horwitz  recommends  two  layers  of  sutures,  first,  interrupted 
Lembert,  second,  mattress. 

Personally  I  feel  "that  in  silk  there  is  greater  safety,  and 
still,  in  view  of  the  fact  that  in  my  own  case  a  part  of  the  silk 
was  afterwards  extruded  into  the  bladder,  became  encrusted 
and  had  to  be  removed,  I  should  hesitate  to  use  it  in  an  exactly 
similar  case.  If  the  wound  is  extra-peritoneal  and  there  has 
been  no  opening  into  the  peritoneal  cavity,  then  one  can  take 
greater  risks  of  leakage  with  little  increase  of  danger. 

The  questions  as  to  leaving  provision  for  drainage  in  the 
wound  and  a  permanent  catheter  in  the  bladder  must  be  regu- 
lated by  the  judgment  of  the  operator.  If  the  operator  has 
confidence  in  the  security  of  his  closure  it  is  far  better  to  pro- 
ceed with  the  operation  for  the  cure  of  the  hernia,  as  otherwise 
it  will  necessitate  subjecting  his  patient  to  a  second  operation. 
The  use  of  a  catheter  retained  in  the  bladder  four  or  {\ye  davs 
would  certainly  seem  indicated,  but  recent  writers  rather  favor 
reliance  upon  either  catheterization  or  voluntary  urination 
every  two  hours.  Again  I  say,  if  there  is  a  possibility  of  leakage, 
into  the  abdominal  cavity  the  catheter  should  be  retained  for 
constant  drainage:  but  if  the  danger  is  only  of  an  extra-peri- 
toneal vesical  fistula  I  might  rely  upon  frequent  catheterization. 


CHAPTER  XIV. 

SURGICAL  CURE  OF  INGUINAL  HERNIA 
IN  THE  FEMALE. 

The  operations  described  in  the  preceding  pages  are  ideal 
when  apphed  to  the  inguinal  canal  of  the  female,  where  we 
have  no  cord  to  deal  with.  In  many  operations  the  round  liga- 
ment has  not  been  seen  and  the  canal  has  been  obliterated  with- 
out any  regard  to  its  whereabouts.  In  a  few  cases,  however, 
it  will  be  found  as  large  as  a  moderate-sized  spermatic  cord  and 
should  be  treated  exactly  the  same;  that  is,  it  should  be  lifted 
out  of  its  bed  and  the  internal  oblique  muscle  closed  beneath  it, 
after  the  sac  is  tied  off  and  cut  away. 

In  some  cases  of  congenital  hernia  in  the  female,  where 
the  process  of  peritoneum  corresponding  with  the  tunica 
vaginalis  in  the  male  was  unobliterated,  and  so  intimately 
blended  with  the  round  ligament  as  to  make  separation  impos- 
sible, the  entire  mass  was  ligated  and  cut  away.  In  these 
cases  a  purse-string  suture  is  put  around  the  inside  of  the 
sac  first  and  then  the  ligature  passed  around  ligament  and 
sac.  The  stump  has  then  been  firmly  stitched  to  Poupart's 
ligament  and  the  internal  oblique  near  the  internal  ring.  In 
former  times  the  Alexander  operation  for  shortening  the  round 
ligaments  resulted  in  a  large  percentage  of  hernias,  owing  to  the 
fact  that  the  work  was  all  done  at  the  external  ring.  Gyne- 
cologists of  the  present  day  usually  open  the  entire  canal  and 
close  it  by  the  Bassini  method. 

Dr.  Charles  P.  Noble  of  Philadelphia,  who  has  had  a 
large  experience,  says  (Reprint,  Lackawanna  Co.  Medical 
Society,  March  28,  1905):  "If  the  ligament  is  pulled  out 
through  the  external  ring  the  process  of  peritoneum  may  be 
pulled  down  and  a  hernia  invited."  Traction  upon  the  ligament 
will  always  bring  a  peritoneal  pouch  into  the  upper  part  of  the 

292 


SURGICAL  CLRE:  FEAL\LE.  293 

canal,  and  if  this  is  left  unobliterated  it  forms  a  convenient 
pocket  into  which  intestine  or  omentum  is  almost  sure  to  drop, 
eventually  forming  a  good  sized  hernia.  A\'hen  the  canal  is 
open  it  is  easy  to  push  back  and  strip  away  this  peritoneum 
before  anchoring  the  ligament  and  closing  the  canal.  In  this 
connection  S.  Goldner  has  made  a  valuable  study  ("  Does  the 
Injury  to  the  Round  Ligament  in  Herniotomy  Cause  Retrode- 
viation of  the  Uterus?" — Zcntralblatt  fur  Gyndkologie,  August 
I,  1903.  Li  50  women  who  underwent  Bassini's  radical 
operation  he  examined  28  in  from  three  to  six  years  after  the 
operation.  In  13  cases  the  operation  was  bilateral  and  in  15 
unilateral.  These  patients  belonged  to  the  working  class  and 
went  back  to  their  labors  undisturbed  and  free  from  pain.  Of 
especial  interest  was  the  condition  of  12  in  whom  the  round 
ligament,  on  account  of  adhesions,  was  cut  through  and  the 
stump  of  the  hernial  sac  ligated  with  the  round  ligament ;  in  6 
cases  this  was  done  on  one  side  and  in  3  cases  on  both  sides, 
and  in  none  of  them  was  there  any  change  in  the  position  of 
the  uterus.  This  condition  led  him  to  conclude  that  the  sever- 
ing of  the  round  ligaments  in  the  inguinal  canal  caused  no  dis- 
advantageous results,  and  that  the  fact  that  even  in  those  cases 
in  which  both  ligaments  were  severed  no  retroflexion  occurred, 
justified  the  use  of  the  radical  operation  of  Bassini. 

My  own  experience  has  been  that  in  1,300  hernia  opera- 
tions, 306  were  in  the  female;  of  these  there  were  156  inguinal 
hernise,  25  being  double.  Five  had  inguinal  hernia  on  one 
side  and  femoral  on  the  other ;  i  had  inguinal  on  one  side  and 
double  femoral ;  2  had  inguinal  and  femoral  hernia  on  the  same 
side ;  i  had  double  inguinal  and  umbilical ;  i  had  inguinal  and 
umbilical.  When  more  than  one  hernia  existed  all  were  oper- 
ated upon  at  a  single  auccsthesia.  Incidentally  other  surgical 
work  was  frequently  done  upon  the  patient  where  needed,  as 
curetting,  cervical,  and  perineal  operations,  for  hremorrhoids. 
or  the  removal  of  small  tumors.  In  none  of  these  cases  was 
there  any  untoward  result,  nor  has  there  been  a  single  recur- 
rence so  far  as  known.     One  of  these  women  had  experienced  5 


294 


ABDOMINAL  HERNIA. 


previous  failures  to  cure  a  small  inguinal  hernia,  and.  I 
removed  5  or  6  large  silver  wire  sutures  that  had  been  left  in 
the  canal.  This  case  was  particularly  instructive  in  the  fact 
that  apparently  in  none  of  the  previous  operations  had  any 
attempt  been  made  to  bring  the  internal  oblique  muscle  down  to 
Poupart's  ligament. 

Fig.  162. 


Continuous  suture  in  muscular  and  aponeurotic  layers  as  used  in  the  female. 

In  the  case  of  the  double  femoral  hernia  the  woman  was 
forty-three  years  of  age,  and  the  operation  was  for  left 
strangulated  femoral  hernia  caused  by  the  incarceration  of  an 
epiploica  appendix,  which  held  a  portion  of  the  lumen  of  the 
intestine  in  the  femoral  ring.  In  the  inguinal  canal  on  the 
same  side  was  found,  firmly  adlierent,  the  tul)e  and  ovary.  The 
sac,  inchiding  ovary  and  tulDC,  was  tied  off  and  cut  away.  The 
patient  was  out  of  bed  on  the  tenth  day  and  left  the  sanitarium 


SURGICAL  CURE:  FEMALE.  295 

on  the  fourteenth  cured  of  her  three  hernise  and  of  much 
obscure  abdominal  pain  from  which  she  had  suffered  for  many 
years. 

The  operation  for  cure  is  done  in  the  female  in  every 
respect  as  in  the  male  except  that  the  canal  is  wholly  obliter- 
ated. I  have  found  it  very  convenient  and  effective  to  close 
the  canal  in  the  female  by  a  single  suture  for  both  the  deep 
muscles  and  the  aponeurosis  of  the  external  oblique  (fig.  162). 
The  suture  begins  at  the  internal  ring,  bringing  the  lower  edge 
of  the  internal  oblique  and  transversalis  in  contact  with 
Poupart's  ligament  all  of  the  way  down  to  the  pubic  bone.  The 
blunt  needle  used,  is  then  made  to  perforate  the  aponeurosis 
near  its  insertion  into  the  pubic  bone  to  the  inner  side,  and  then 
through  the  external  pillar  of  the  ring  externally.  When  this 
is  tightened  it  practically  obliterates  the  external  ring.  The 
remainder  of  the  continuous  suture  can  be  rapidly  placed,  the 
second  and  last  knot  being  tied  just  above  the  upper  angle  of 
the  split  aponeurosis.  The  time  required  to  operate  on  the 
female  is  less  than  on  the  male  and  the  results  are  even  more 
satisfactory,  yielding  in  my  own  experience  100  per  cent, 
permanent  cures. 

The  question  of  operating  for  the  cure  of  hernia  upon 
women  who  are  pregnant  is  one  that  will  come  to  most 
operators.  In  three  instances  I  have  operated  upon  women 
who  were  in  the  early  months  of  pregnancy.  In  e\'ery 
instance  they  were  less  than  four  months  advanced  and.  as 
would  be  expected,  no  unpleasant  symptoms  followed.  It  is 
inadvisable  to  do  surgical  work  upon  a  pregnant  woman  unless 
especially  called  for,  as  in  these  cases. 

I  have  recently  been  called  upon  to  decide  between  two 
physicians  as  to  whether  or  not  an  abortion  was  justifiable  upon 
a  woman  three  and  a  half  months  advanced  in  pregnancy 
because  of  her  having  an  uncontrollalDle  femoral  heniia.  It  was 
not  an  unreasonable  question  in  view  of  the  fact  that  the 
woman  had  once  required  an  operation  for  the  strangulation  of 
this  same  hernia.    My  decision  was,  as  it  probably  would  be  in 


296  ABDOMINAL  HERNIA. 

every  other  similar  case,  that  such  an  act  was  entirely  unjusti- 
fiable in  view  of  the  fact  that  women,  even  though  suffering 
from  extremely  bad  hernise,  seldom  have  any  trouble  with  them 
during  pregnancy  or  confinement.  This  is  more  especially  true 
of  inguinal  or  femoral  hernia  for  the  reason  that  as  soon  as  the 
uterus  begins  to  occupy  the  pelvis  and  lower  abdomen,  the 
intestines  and  omentum  are  lifted  up  and  away  from  the  hernial 
openings.  It  not  uncommonly  happens  that  in  the  last  months 
of  pregnancy  a  large  hernia  will  disappear  and  not  protrude 
even  if  no  truss  is  worn.  Women  frequently  are  deceived  by 
this  into  the  belief  that  they  are  cured  and  make  the  mistake 
of  getting  up  after  confinement  without  applying  a  truss. 


CHAPTER  XV. 
FEMORAL    HERNIA. 

Eight  per  cent,  of  all  hernise  are  of  the  femoral  type,  and 
it  occurs  more  frequently  in  the  female  than  in  the  male,  as 
shown  by  the  fact  that  of  all  women  suffering  from  hernia, 
38  per  cent,  have  this  variety.  According  to  Macready 
(Treatise  on  Ruptures)  women  during  the  child-bearing  period 
have  inguinal  and  femoral  about  equally,  but  after  fifty  years 
of  age  femoral  hernia  is  slightly  in  excess.  In  men  between 
twenty-one  and  sixty-five  years  of  age,  3.9  per  cent,  have 
femoral  hernia,  but  among  bakers,  as  a  separate  class,  it  exists 
to  the  extent  of  8.7  per  cent.  It  is  the  most  dangerous  of  all 
hernise,  not  only  on  account  of  its  greater  liability  to  strangu- 
lation, but  owing  to  the  fact  that  when  strangulation  does 
occur  the  destructive  process  is  much  more  rapid  than  in  any 
other  form.  This  latter  fact  is  undoubtedly  due,  first,  to  the 
inelastic  structures  which  surround  the  femoral  canal,  and 
second,  to  the  knife-like  edges  against  which  the  intestine  or 
other  protruding  abdominal  viscera  are  violently  pressed. 

This  variety  of  hernia  is  seldom  encountered  before  early 
youth,  and  most  frequently  occurs  in  later  life.  The  youngest 
case  met  with  in  the  author's  experience  was  in  a  boy  four  years 
of  age  who  had  double  femoral  hernia  of  nearly  one  year's 
duration.  Another  boy  of  eight  years  had  right  femoral,  and 
the  youngest  girl,  also  eight  years  old,  had  right  side  hernia. 
That  it  seldom  or  never  occurs  in  infancy  is  due  to  the 
anatomical  fact  that  in  early  childhood  the  calibre  of  the 
femoral  opening  is  very  small,  enlarging  as  adult  life 
approaches. 

This  form  of  hernia  may  be  single  or  double,  and  may  be 
associated  with  inguinal  hernia  on  either  the  opposite  side  or  the 
same  side.     The  author  has  seen  one  case  of  double  inguinal 

297 


298 


ABDOMINAL  HERNIA. 


and  double  femoral  hernia  in  the  same  person.  It  may  be 
reducible,  irreducible,  or  strangulated.  It  is  seldom  irreducible 
without  producing  symptoms  of  strangulation,  and  in  this  it 
differs  markedly  from  either  inguinal  or  umbilical  hernia, 
where  we  may  find  large  masses  of  omentum  or  even  intestine 
which  do  not  produce  any  great  amount  of  discomfort. 

Fig.  163. 


Femoral  region.  A,  Poupart's  ligament.  B,  Anterior  crural  nerve.  C,  Crural  branch 
of  genilo-crural  nerve.  D,  Femoral  artery.  E,  Gimbeniat's  ligament.  F,  Femoral  vein. 
G,  Fascia  lata  cut  away  to  show  head  of  pectineus  muscle. 


ANATOMY. 

Poupart's  ligament  is  a  strong,  fibrous  band  extending 
from  the  anterior-superior  spine  of  the  crest  of  the  ilium,  to  the 
spine  of  the  pubes  separating  the  abdomen  from  the  thigh  (fig. 
163).  Beneath  this  structure  (between  it  and  the  pubic  bone) 
are  the  parts  most  concerned  in  the  formation  of  femoral 
hernia.     The  transverse  section  of  these  parts  is  shown  in  the 


FEMORAL  HERNIA. 


299 


accompanying  illustration,  and  a  brief  study  of  this  will  give  a 
clearer  idea  of  the  relative  position  of  the  parts  than  can  be 
given  by  mere  description  (fig.  164). 

Gimbernat's  Ligament  (fig.  163)  is  attached  to  the  ileo- 
pectineal  line  from  the  spine  of  the  pubes  outwards,  and  fills  the 
triangle  between  this  line  and  Poupart's  ligament,  its  base 
being  directed  toward  the  femoral  vein.     Its  total  length  is 


Poupart's  ligament 


Gimbernat's 
ligament 


Anterior  crural 
Crural  b'h  gen-crural 

Psoas  m. 

Femoral  artery 
Sheath  of  vessels 
Femoral  vein 

Femoral  ring 


Transverse  section  showing  relation  of  vessels  and  nerves  to  femoral  canal. 

from  two-thirds  to  three- fourths  of  an  inch.    Immediately  back 
of  it  is  the  conjoined  tendon. 

The  Femoral  Ring  lies  to  the  outside  of  the  base  of  Gim- 
bernat's ligament  between  that  and  the  femoral  vein,  and  is 
bounded  above  by  Poupart's  ligament  and  below  by  the  ramus 
of  the  pubes.  Hesselbach  has  given  its  measurement  as  10 
mm.  in  the  female  and  5  mm.  in  the  male.  The  femoral  ring  is 
ordinarily  filled  with  subperitoneal  fat  and  sometimes  a  small 
gland.     When  standing  it  is  nearly  horizontal. 


300 


ABDOMINAL  HERNIA. 


Diagram  Showing  Formation  and   Covering  of  Femoral  Hernia  ; 
Protusion  of  Extra  Peritoneal  Fat  and  Lipoma. 


Diagram  showing  parts  involved  in 
femoral  hernia.  The  arrow  shows  line 
of  descent.  A,  Subcutaneous  fat.  I,  Mus- 
cular wall.  B,  Fascia  lata.  C,  Cribriform 
fascia.  E,  Femoral  sheath  (transversalis 
fascia  near  its  junction  with  iliac  fascia"). 
F,  Peritoneum.  G,  Extra-peritoneal  fat. 
H,  Pubic  bone. 


Femoral  hernia.  A,  Subcutaneous  fat. 
B,  Fascia  lata.  C,  Cribriform  fascia.  D, 
Hernial  sac.  E,  Femoral  sheath  (trans- 
versalis fascia).  F,  Peritoneum.  G,  Extra- 
peritoneal fat.     H,  Pubic  bone. 


Fatty  hernia  through  femoral  canal.  D, 
Extra-peritoneal  fat. 


J,  Fatty  tumor.     Not  fixed  below,  but  freely 
movable  in  subcutaneous  tissue. 


FEMORAL  HERNIA. 


301 


Femoral  Sheath. — The  transversalis  fascia,  covering  the 
anterior  wall  of  the  abdominal  cavity,  passes  clown  under 
Poupart's  ligament  and  forms  the  anterior  layer  of  the  femoral 
sheath,  while  the  iliac  fascia  forms  its  posterior  layer  and  is 

Fig.  165. 


(Redrawn  from  Gray.)  A,  Showing  small  pocket  by  side  of  femoral  vessels,  where  hernia 
usually  protrudes,  breaking  down  Gimbernat's  ligament  and  forming  an  elongated,  triangular 
opening.  The  top  of  this  triangle  is  Poupart's  ligament ;  the  floor,  the  tissues  covering  the 
ramus  of  the  pubes  ;  its  base,  the  femoral  vessels  ;  and  its  point,  the  spine  of  the  pubes.  B, 
Femoral  artery.     C,  Femoral  vein.     D,  Saphenous  vein. 

continuous  with  that  on  the  pectineus  muscle.  The  meeting 
and  blending  of  these  layers  of  fascia  form  a  funnel-shaped 
space  termed  the  femoral  canal,  which  is  about  half  an  inch  in 
length.      Hernia  protruding  through  this  opening  carries  before 


302 


ABDOMINAL  HERNIA. 


it  this  fascia  and  subperitoneal  fat.  The  fascia  is  sometimes 
so  dense  as  to  lead  the  operator  to  suppose  that  he  is  dealing 
with  the  hernial  sac.  At  other  times  the  tissues  covering  a 
femoral  sac  are  so  thin  that  it  is  only  by  extreme  care  that  they 
can  be  incised  without  opening  into  the  sac. 

The  most  common  point  of  protrusion  of  femoral  hernia 
is  within  this  sheath  between  the  femoral  vessels  and  the  outer 

Fig.  1 66. 


Double  femoral  hernia,  in  a  man  of  50  years.  Typical  illustration  of  fairly  large  femoral 
hernia.  On  the  left  the  tumor  has  turned  up  partially  over  the  external  ring,  but  its  centre  is 
below  the  crease  formed  by  the  junction  of  the  thigh  and  abdomen. 

edge  of  Gimbernat's  ligament.  Below  the  sheath  is  the 
pectineus,  and  at  the  outer  side  the  psoas  muscle.  To  the 
outer  side  of  the  femoral  sheath  close  to  Poupart's  ligament  is 
the  crural  branch  of  the  genito-crural  nerve. 

Femoral  protrusions  leave  the  abdominal  cavity  by  escap- 
ing beneath  Poupart's  ligament,  and  passing  to  the  inner  side 
of  the  femoral  vessels  (fig.  165).  Gimbernat's  ligament  is 
crowded  towards  the  median  line.  It  is  this  thin  tendon  which 
ordinarilv  produces  the  knife-edge  cutting  of  the  bowel  that  is 


FEMORAL  HERNIA. 


303 


so  destructive  in  strangulated  hernia  of  this  type.  These  pro- 
trusions escape  from  beneath  the  fascia  lata  at  the  saphenous 
opening,  penetrating  or  carrying  before  them  the  cribriform 
fascia,  and  form  a  tumor  on  the  anterior  and  inner  aspect  of  the 
thigh  three-cjuarters  of  an  inch  to  the  outer  side  of,  and  the 
same  distance  below,  the  spine  of  the  pubes.  The  long  diameter 
of  the  femoral  opening,  after  hernia  has  distended  it,  is  trans- 


FlG.  167. 


Side  view.  Front  view. 

Reducible  femoral  hernia  of  enormous  size.    This  hernia  was  reducible  and  could  be  retained 

by  a  truss. 

verse,  or  parallel  with  the  ramus  of  the  pubes,  and  is  triangular 
in  shape,  the  term  "  Ring  "  being  a  misnomer. 

Considering  the  parts  from  within,  we  have  first,  the  peri- 
toneum; second,  the  extra-peritoneal  fat;  third,  the  transver- 
salis  fascia,  which  forms  the  sheath  of  the  femoral  vessels; 
fourth,  subcutaneous  tissue ;  and  fifth,  skin.  The  vessels  of  the 
region  are  important  and  should  be  clearly  fixed  in  mind,  but 
their  proximity  need  cause  no  timidity  on  the  part  of  the 


304  ABDOMINAL  HERNIA. 

careful  operator.  The  saphenous  vein  passes  over  the  falci- 
form edge  of  the  fascia  lata  to  join  the  femoral  vein,  and  here 
also  are  given  off  from  the  femoral  artery  the  external  pubic, 
the  external  epigastric  and  the  circumflex  iliac  arteries. 

Formation. — Femoral  hernia  usually  develops  by  a  slow 
process,  frecjuently  attended  by  some  pain  or  a  dull  aching  in 
that  region  and  extending  down  the  leg.  This  is  often 
described  as  a  burning  sensation.  In  many  instances,  as  in 
inguinal  hernia,  a  swelling  in  the  femoral  space  is  the  first 
indication  of  anything  wrong  observed  by  the  patient. 

There  is  little  doubt  that  the  subperitoneal  fat  frecjuently 
acts  as  the  entering  wedge  and  is  the  forerunner  of  the  hernia. 
Under  some  violent  strain  it  is  forced  into  the  femoral  sheath, 
and,  slipping  under  Poupart's  ligament,  presents  a  small  tumor 
at  the  saphenous  opening.  Shortly  following  this  the  peri- 
toneum, dragged  down  by  the  attached  fat,  and  pressed  upon 
from  within  by  the  abdominal  contents,  is  sure  to  be  found 
protruding,  and  the  hernia  well  established.  Ordinarily 
femoral  hernia  does  not  attain  a  very  great  size,  but  pre- 
sents a  small,  round  tumor  varying  in  size  from  a  hickory- 
nut  to  that  of  a  good-sized  hen's  e.gg  (fig.  i66).  As  a  rule 
femoral  hernia  remains  small;  as  in  other  forms  of  hernia, 
however,  there  may  be  great  variation  in  its  size  and  shape. 
The  enormous  proportions  that  they  may  assume  when 
neglected  is  well  shown  in  the  cases  here  illustrated. 

Fig.  167  shows  the  case  of  a  man  50  years  of  age,  in  good 
general  health,  who  was  being  supported  by  a  Hebrew  chari- 
table institution  for  complete  disability.  The  hernia  was 
considerably  larger  than  the  patient's  head.  Notwithstanding 
total  lack  of  treatment  for  man}^  years,  the  hernia  could  be 
completely  reduced  to  the  abdominal  cavity  and  comfortably 
retained  bv  truss  pressure.  The  man  was  doing  perfectly  well 
under  truss  treatment  until  it  occurred  to  him  that  he  was 
losing  his  only  possible  claim  upon  the  institution,  after  which 
nothing  could  be  done  willi  liim.  nor  would  he  consent  to 
operative  cure,  which  Could  most  certainly  have  been  afforded 


FEMORAL  HERNIA. 


305 


him.  The  photograph  shown  in  fig.  i68  is  of  a  woman  fifty-five 
years  of  age,  who  had  an  enormous  irreducible  femoral  hernia. 
The  full  size  of  this  hernia  is  not  shown  in  the  photograph,  as  it 
had  not  only  formed  down  on  the  thigh,  but  had  dissected  up 
the  skin  from  the  fascia  around  toward  the  back  part  of  the  leg. 

Fig.  1 68. 


Woman  55  years  of  age.  Irreducible  femoral  hernia.  Extent  of  tumor  not  shown  here,  as 
it  extended  well  around  to  back  of  thigh.  Contents,  intestine  with  a  large  mass  of  adherent 
omentum.    Cured  by  operation. 


Hernise  of  this  size  are  pretty  sure  to  be  made  up  largely 
of  omentum,  as  in  this  case,  but  the  author  has  seen  one  case 
fully  as  large  where  the  protruding  content  was  entirely  intes- 
tine and  irreducible.  The  case  referred  to  is  shown  in  fig.  169. 
This  photograph  fails  to  show  the  full  proportions  of  the 
tumor,  or  another  femoral  hernia  that  existed  on  the  opposite 
side.     This  tumor  also  extended  around  to  the  inner  side  of 

20 


306 


ABDOMINAL  HERNIA. 


the  thigh.  Upon  operating,  the  right-side  hernia  was  found  to 
consist  of  intestine  held  upon  a  mesentery  so  thick  and  inflex- 
ible that  reduction  appeared,  at  first,  impossible.  No  adhe- 
sions existed,  and  no  omentum  was  found  protruding.  Reduc- 
tion was  finally  accomplished  and  the  greatly  distended  femoral 
opening  closed.  The  opposite  side  was  also  operated  upon. 
The  patient,  more  fortunate  than  my  one  other  instance  of 

Fig.  169. 


Double  femoral  hernia  in  woman  aged  48  years.  Right  side  only  shown  and  not  in  its  full 
size.  Irreducible.  Contents,  intestine  held  down  by  hypertrophied  mesentery.  No  adhe- 
sions.   No  omentum.    Both  herniae  cured  by  operation  on  the  same  day. 

mesentery  of  this  peculiar  type,  made  a  prompt  recovery  and 
remains  sound  four  years  later.     No  truss  has  been  worn. 

The  dangers  of  acute  strangulaton  are  not  quite  as  great 
in  herni?e  of  such  large  size  as  in  the  smaller  ones,  inasmuch  as 
they  protrude  through  such  enormously  distended  rings ;  they 
are  cjuite  likely,  however,  to  eventually  reach  a  fatal  termina- 
tion where  the  bowel  forms  a  large  part  of  the  protruding 
contents  and  is  irreducible.  This  comes,  first,  with  obstinate 
constipation,  gradually  increasing  to  intestinal  obstruction  and 
death.  Tt  is  due  to  the  fact  that  the  bowel,  in  its  abnormal 
position,   under  pressure  at  the  abdominal   orifice,   gradually 


FEMORAL  HERNIA. 


307 


loses  its  peristaltic  action  and  when  obstruction  occurs,  an 
operation  returns  bowel  which,  while  it  may  be  otherwise  in 
good  condition,  is  paralyzed  beyond  recovery. 

The  sacs  of  femoral,  like  those  of  inguinal  hernia,  may 
also  be  modified  in  shape  by  bands  of  connective  tissue  form- 
These  bands  become  fibrous  in  character 


ing  in  the  interior. 


Fig.  170. 


Cyst  of  old  hernial  sac.     A,   Cyst.     B,   Point   of   closure.    C,  Interior  of  sac. 
D,    Femoral  ring. 

and  add  materially  to  the  risk  of  strangulation.  The  neck  of 
the  femoral  sac,  where  it  passes  under  Poupart's  ligament,  is 
usually  very  small  and  this  in  itself  becomes  a  source  of  danger 
to  the  protruding  parts.  The  sac  becomes  tough  and  thick- 
ened at  this  point,  and  in  some  rare  instances  where  a  truss  has 
been  constantly  worn,  is  closed  off  entirely.  This  closure  is 
temporary  in  character  and  does  not  result  in  a  cure.     A  sac 


308 


ABDOMINAL  HERNIA. 


that  has  been  closed  off  in  this  manner  is  quite  hkely  to  take  on 
a  conchtion  of  hydrocele,  and,  as  it  occupies  the  exact  site  of  the 
former  hernia,  is  very  likely  to  be  mistaken  for  irreducible 
femoral  hernia.  Such  a  case  is  illustrated  in  a  drawing  (fig. 
170),  made  from  a  sac  removed  from  a  patient  supposed  to 
have  irreducible  hernia.  The  hernia  proper  was  in  the  upper 
13art  of  the  sac  and  easily  reduced. 

Fig.  171- 


Irreducible  femoral  hernia  of  peculiar  shape  in  a  woman  of  38  years,  due  to  resisting  bands  of 
fascia.     Adherent  intestine  in  sac.    Cured  by  operation. 


The  shape  of  the  sac,  and  even  the  exterior  surface  of  the 
hernia,  may  be  modified  by  resisting  vessels  or  fascia  as  it 
descends  through  the  short  canal  or  as  it  lifts  up  the  cribriform 
fascia  at  the  saphenous  opening.  A  case  with  a  lobulated  sac 
from  the  latter  cause  is  shown  in  fig.  171.  The  patient  was  a 
woman  thirty-eight  years  old  and  had  the  hernia  for  eight 
or  ten  vears.     Trusses  tried  in  this  case  could  not  be  tolerated 


FEMORAL  HERNIA.  309 

because,  as  was  found  on  the  operating  table,  she  had  bowel 
adherent  in  the  sac.  Both  bowel  and  omentum  were  found, 
the  latter  being  ligated  and  removed.  It  is  due  to  these  resist- 
ing bands  that  occasionally  a  femoral  sac,  instead  of  forming 
below  the  opening  through  which  it  protrudes,  turns  upwards 
over  Poupart's  ligament  and  simulates  inguinal  hernia. 

Macready  {Treatise  on  Ruptures,  p.  60)  gives  an  illustra- 
tion of  a  case  where  three  femoral  sacs  were  found  upon  the 
same  side  in  one  patient,  and  it  is  mentioned  here  to  show 
the  possibility  of  a  sac  protruding  at  unusual  places.  In 
Macready's  case  one  protrusion  was  through  Gimbernat's  liga- 
ment close  to  the  spine  of  the  pubes,  one  at  its  usual  place,  and 
the  third  just  to  the  outer  side  of  the  femoral  vessels.  The 
condition  was  not  recognized  during  life. 

The  contents  of  a  femoral  sac  may  be  almost  any  of  the 
movable  organs  of  the  pelvic  or  abdominal  cavity.  Intestine 
is  most  commonly  found,  omentum  next  in  frequency,  but 
there  are  many  recorded  cases  of  tubes  and  ovaries,  the  appen- 
dix and  the  bladder,  being  found. 

The  subject  of  appendicular  femoral  hernia  has  been  care- 
fully stuched  by  Dr.  Alfred  C.  Wood  of  Philadelphia  {Annals 
of  Surgery,  May,  1906,  p.  668).  He  has  collected  100  cases, 
from  that  of  Garangeot,  1 731,  to  his  own  2  cases.  He  has  col- 
lected only  those  cases  where  the  appendix  occupied  exclusively 
the  sac  of  a  femoral  hernia.  Those  where  other  portions  of 
the  intestine  were  present  have  been  excluded.  "  Of  the  100. 
cases  of  appendicular  femoral  hernia,  81  were  women,  7 
men,  12  sex  not  given.  Youngest  19  years,  oldest  87.  More 
than  half  were  over  50  years,  and  over  85  per  cent,  were  past 
40.     Diagnosis  previous  to  operation  quite  unusual." 

DIAGNOSIS    OF    FEMORAL    HERNIA. 

In  many  instances  it  is  more  difficult  to  make  a  diagnosis 
of  femoral  hernia  than  of  the  inguinal  variety,  and  not 
infrecjuently  distinction  between  the  two  is  attended  by  great 
uncertainty.     The  author  has  seen  2  patients  who  had  been 


310  ABDOMINAL  HERNIA. 

operated  upon  for  inguinal  hernia  where  the  femoral  type 
existed,  and,  of  course,  as  soon  as  the  patients  were  on  their 
feet,  the  herniae  protruded  again.  These  occurred  in  the  prac- 
tice of  men  well  known  in  connection  with  abdominal  surgery. 
In  one  case  the  operator  told  of  failing  to  find  any  sac,  and 
later,  when  the  femoral  hernia  appeared,  it  dawned  upon  him 
why  he  had  failed.  In  both  cases  the  patients  refused  to  allow 
the  original  operator  to  operate  again  and  were  suspicious  as 
to  the  true  reason  of  failure. 

Colicky  abdominal  pains  are  very  likely  to  be  present  dur- 
ing the  formation  of  femoral  hernia  if  the  intestine  forms  a 
portion  of  the  protruding  contents,  but  if  it  contains  omentum 
alone,  this  may  not  cause  the  patient  sufficient  annoyance  to 
attract  attention.  In  a  case  recently  seen  of  strangulated 
omentum  in  a  left  side  femoral  hernia,  the  patient  complained 
of  a  dragging  in  the  lower  part  of  the  abdomen  on  the  right 
side.  Even  where  the  intestine  is  strangulated,  the  pain  is  far 
more  likely  to  be  abdominal  than  local. 

If  femoral  hernia  forms  a  small,  round,  typical  reducible 
swelling  in  Scarpa's  triangle,  then  the  case  is  very  clear,  and 
the  diagnosis  easy;  but  in  the  descent  it  may  come  in  contact 
with  resisting  tissues  that  turn  it  up  over  Poupart's  ligament 
directly  over  the  inguinal  canal.  In  reducing  such  a  tumor  it 
must  be  followed  in  the  line  of  least  resistance,  and  then  it  will 
be  traced  to  its  true  origin.  If  it  is  not  reducible,  by  lifting  it 
up  and  away  from  the  abdominal  wall,  its  neck  may  be  sur- 
rounded and  its  point  of  exit  located. 

The  anatomical  points  that  must  be  constantly  borne  in 
mind  in  deciding  between  femoral  and  inguinal  hernia  are  the 
anterior-superior  spine  of  the  crest  of  the  ilium  and  the  spine 
of  the  pubes ;  an  imaginary  line  drawn  between  the  two  with  a 
slight  downward  curve  representing  Poupart's  ligament.  This 
line  is  roughly  represented  by  the  crease  between  the  thigh  and 
the  abdomen,  and  is  clearly  shown  in  most  people.  The  top 
of  a  femoral  hernia  just  touches  this  crease,  and  an  inguinal 
protrusion    is    above    it.       Furthermore,    an    inguinal    hernia 


FEMORAL  HERNIA.  311 

usually  travels  up  the  canal  as  reduced,  while  in  femoral  hernia 
reduction  is  directly  back  towards  the  thigh  as  it  passes  into  the 
saphenous  opening  and  slips  under  Poupart's  ligament.  In 
direct  inguinal  hernia  the  differential  points  may  be  more 
obscure,  owing  to  its  very  close  j)roximity  to  the  femoral  open- 
ing and  to  the  fact  that  it  reduces  directly  backwards.  Here 
the  spine  of  the  pubes  must  be  the  guide,  remembering  that  the 
femoral  opening  is  three-cjuarters  of  an  inch  to  the  outer  side 
and  about  the  same  distance  below  that  point,  and  that  the 
direct  inguinal  protrusion  is  almost  immediately  above  the 
spine.  Another  point  of  difference  is  that  usually  the  inguinal 
variety  can  be  easily  reduced  with  the  patient  standing,  by 
making  pressure  with  the  hand,  while  in  femoral  hernia  it  is 
almost  always  impossible  to  reduce  the  tumor  until  the  patient 
has  been  placed  in  the  recumbent  posture,  and  even  then  reduc- 
tion takes  place  very  slowly.  It  is  well  to  look  with  extreme 
suspicion  upon  any  tumor  in  the  femoral  space  that  is  easily 
reduced  while  the  patient  is  standing.  In  the  male  much 
valuable  information  may  be  obtained  by  invaginating  the  thin 
tissues  of  the  scrotum  upon  the  finger,  following  the  cord  up  to 
the  external  ring"  and  carefully  examining  the  condition  of  the 
external  ring  as  well  as  locating  the  relative  position  of  the 
tumor.  With  the  tip  of  the  finger  in  the  external  ring  it  can 
usually  be  decided  whether  the  protrusion  is  to  its  inside, — 
direct  hernia, — or  to  its  outer  side  and  a  little  lower, — femoral 
hernia. 

Here  the  author  would  again  caution  the  examiner 
against  passing  the  finger  iip  the  canal.  Such  method  of 
examining  the  canal  is  reprehensible  and  may  lead  to  hernia 
where  none  exists. 

There  is  one  small  round  tumor  forming  in  the  femoral 
space  that  is  easily  reducible,  that  has  the  typical  shape  of 
femoral  hernia,  and  that  is  frequently  mistaken  by  the  examiner, 
viz.,  a  varicose  condition  of  some  of  the  vessels  of  this  vicinity. 
Varix  of  some  of  the  larger  vessels  of  this  region  may 
prove  very  perplexing  to  those  of  moderate  experience   (fig. 


312  ABDOMINAL  HERNIA. 

172).  The  points  of  differential  diagnosis  are  first,  and  most 
important,  great  ease  of  reduction  in  varix ;  second,  the  fluid 
feel  of  the  contents  and  peculiar  impulse  upon  coughing. 

Fig.  172. 


A  left  varicose  saphena  vein.    {Eccles.) 

Femoral  hernia,  as  previously  stated,  is  slow  and  rather 
difficult  of  reduction,  and  it  is  almost  always  a  necessity  that 
the  patient  should  be  recumbent  before  it  can  be  accomplished. 
Varix,  on  the  contrary,  is  soft  and  readily  compressible  with 
the  patient  in  the  standing  position.  By  pressure  over  it  with 
the  hand  it  quickly  disappears  and  as  quickly  returns  when  the 


FEMORAL  HERNIA. 


313 


pressure  is  removed.  Furthermore,  there  is  a  strong  impulse 
in  the  varix  when  the  patient  coughs  which  does  not  exist  in 
femoral  hernia.  The  impulse  gives  the  sensation  of  "  thrill  " 
rather  than  of  expansion.  It  is  the  impulse  of  fluid,  and  has 
that  characteristic  feel  under  the  fingers.  A  single  varix  of 
this  type  may  exist  without  other  vessels  of  the  region,  or  on 

Fig.  173. 


Femoral  and  labial  varix  in  a  woman  of  35  years,  6  months  pregnant. 

the  lower  leg,  being  affected.  Usually  in  suspected  cases, 
however,  an  examination  of  the  leg  will  reveal  varicose  bunches 
about  the  ankle,  calf,  or  popliteal  space. 

During  pregnancy  some  women  are  very  liable  to  a  con- 
dition of  varix  that  is  mainly  limited  to  the  labia  and  femoral 
region  (see  fig.  173).  In  these  cases  the  suspicious  appearance 
of  the  tumor  and  a  consideration  of  the  general  condition 
usually  lead  to  a  correct  diagnosis.     Varix  occurs  most  fre- 


SU  ABDOMINAL  HERNIA. 

quently  in  women  of  middle  age,  but  I  had  in  my  clinic  during 
the  past  year  a  young  girl  of  eighteen  years  where  the  con- 
dition was  marked  and  perplexing.  The  case  was  afterward 
taken  into  another  hospital  as  one  of  femoral  hernia.  The 
patient's  family  physician,  who  was  present  at  the  operation, 
informed  me  that  no  hernia  was  found,  but  the  varix  was 
tied  off.  I  had  advised  against  this  operation  as  not  necessary 
and  as  attended  by  considerable  danger.  The  following  indi- 
cates the  possible  danger.  Dr.  William  J.  Taylor  {Annals  of 
Surgery  J  July,  1905,  p.  127)  reports  a  case  of  a  woman  thirty 
years  of  age  who  had  been  wearing  a  truss  for  a  supposed 
femoral  hernia.  Upon  operation  he  found  a  varicose  condition 
of  the  saphenous  vein.  He  ligated  the  vein  below  the  enlarge- 
ment and  then  ligated  it  again  three-quarters  of  an  inch  from 
the  femoral  vein.  Seven  days  later  she  went  into  collapse  and 
died  the  ninth  day  after  operation.  Post-mortem  showed  heart 
clot. 

Haberern  reports  (Deutsche  Medizinische  Wochen- 
schrift,  Dec.  20,  1906)  cutting  down  on  what  he  believed  to 
be  incarcerated  femoral  hernia  and  a  gush  of  blood  poured 
out.  The  saphenous  vein  was  tied  off  together  with  the  plexus 
of  inflamed  varicosities.  Patient  recovered.  He  believes  that 
the  difficulties  of  diagnosis  between  incarcerated  femoral  hernia 
and  varicosites  of  this  type  to  be  considerable. 

A  violent  inflammation  of  the  superficial  glands  of  the 
femoral  region  is  seldom  mistaken  for  hernia  because  of  local 
pain,  heat,  and  usually  discoloration  of  the  skin.  In  the  case 
of  glandular  trouble  it  has  a  feeling  of  closeness  to  the  surface 
that  is  seldom  present  in  hernia.  Incarcerated  omentum  in  a 
femoral  sac,  from  which  it  is  most  difficult  to  distinguish  ade- 
nitis, is  usually  accompanied  by  at  least  some  abdominal  discom- 
fort, even  though  actual  pain  is  not  present.  Tlie  author  recently 
o|>erated  upon  a  case  where  the  diagnosis  was  very  uncertain,  as 
there  had  been  considerable  local  pain  and  there  was  fluctu- 
ation. The  tumor  had  a  history  of  two  weeks'  duration  and 
gradual  increase  in  size.     Nine  years  previously  he  had  oper- 


FEMORAL  HERNIA. 


315 


ated  for  femoral  hernia  upon  the  opposite  side  in  the  same 
patient  and  obtained  a  permanent  cure.  The  present  operation 
revealed  a  dark-colored  femoral  sac  filled  with  a  coffee-colored 
fluid,  the  result  of  strangulation  of  a  small  piece  of  omentum. 

Fig.  174. 


Lipoma  simulating  femoral  hernia.     In  this  case  the  lipoma  is  in  the  subcutaneous  fat  and 
does  not  protrude  through  the  femoral  ring. 

The  woman  had  suffered  no  abdominal  symptoms,  and  had 
discomfort,  rather  than  pain,  locally. 

Hydrocele  of  a  sac,  the  neck  of  which  has  been  obliterated 
by  truss  pressure,  may  present  symptoms  almost  identical  with 
those  just  narrated,  but  without  the  local  discomfort.  Its 
elasticity  and  the  smoothness  of  the  surface  of  the  tumor  are 
the  usual  guides.     Between  fluid  tumors  resulting  from  hydro- 


316  ABDOMINAL  HERNIA. 

cele  of  the  sac,  or  from  strangulated  omentum,  it  may  be 
impossible  to  make  an  exact  diagnosis  previous  to  operation, 
as  in  the  case  just  cited.  The  author  has  seen  two  cases  of 
lympho-sarcoma  that  were  at  first  examination  quite  perplex- 
ing, but  fortunately  these  are  of  rare  occurrence. 

Psoas  abscess  is  very  rarely  mistaken  for  femoral  hernia, 
as  it  occurs  most  frequently  in  young  persons  suffering  from 
Pott's  disease  of  the  spine,  and  is  therefore  easily  recognized. 

Subperitoneal  fat,  or  lipoma  (fig.  174),  not  only  fre- 
quently precedes  femoral  hernia,  but  is  easily  mistaken  for  it. 
As  its  treatment  should  be  the  same  as  for  hernia  the  obscurity 
surrounding  the  diagnosis  is  of  no  serious  importance.  If  it 
can  be  reduced  through  the  femoral  opening  it  may  be  retained 
by  a  truss,  and  if  irreducible  it  should  be  removed  by  operation. 

Irreducibility. — Femoral  hernia  becomes  irreducible  more 
than  ten  times  as  often  as  inguinal,  and  the  contents  are 
most  frequently  omentum.  Owing  to  the  smallness  of  the 
neck  of  the  sac  and  the  inelasticity  of  its  surroundings,  it  is 
improbable  that  bowel  would  be  irreducible  without  being 
attended  with  the  usual  violent  symptoms  of  strangulated 
hernia.  Very  rarely,  however,  in  extremely  large  and  old 
herniae  this  may  occur. 


J^W 


CHAPTER  XVL 
MECHANICAL  TREATMENT  OF  FEMORAL  HERNIA. 

In  no  form  of  abdominal  hernia  is  prompt  and  efficient 
treatment  more  important  than  in  that  variety  known  as 
femoral,  nor  is  there  any  form  where  more  diffitulty  is  ex- 
perienced in  carrying  treatment  into  effect.  This  refers  more 
especially  to  its  palliative  or  truss  treatment,  and  is  due  to 
the  extreme  difficulty  of  producing  sufficient  pressure  over 
the  deep-seated  femoral  opening  to  prevent  a  protrusion  through 
it  without  making  intolerable  pressure  on  adjoining  important 
nerves  and  blood  vessels.  Furthermore,  even  if  the  exact 
compression  of  the  canal  has  been  obtained,  nothing  but  the 
most  careful  and  accurate  fitting  of  the  truss  spring  wih  main- 
tain the  location  of  the  pad.  It  is  easily  displaced  by  the 
motions  of  the  leg,  upon  the  muscles  of  which  its  lower  edge 
necessarily  rests,  or  by  the  folding  over  of  the  abdominal  wall 
against  its  top. 

For  these  reasons,  and  for  the  additional  reason  that 
femoral  hernia  is  never  cured  by  truss-wearing,  no  matter  how 
young  the  patient  nor  how  recent  and  small  the  hernia,  this 
form  should  always  have  the  benefit  of  present-day  surgery 
and  be  cured,  unless  there  is  some  other  physical  condition 
which  is  contraindicative.  This  statement  is  not  intended  to 
convey  the  impression  that  there  are  not  hundreds  who  go 
through  life  and  escape  accident,  but  it  means  that  they  are 
much  more  liable  to  accident  and  experience  greater  incon- 
venience from  truss-w^earing  than  those  who  are  afflicted  with 
inguinal  hernia. 

What  has  been  said  of  truss-fitting  in  general,  the  taking 
of  a  diagram  of  the  pelvis,  which  is  especially  important  in 
these  cases,  and  the  shaping  of  truss  springs  need  not  be 
repeated  here. 

317 


318  ABDOMINAL  HERNIA. 

Group  of  Trusses  for  Femoral  Hernia. 


I.     Chase  femoral-hernia  truss,  hard  rubber. 


2.    Chase  femoral-hernia  truss,  cedar  pad,  leather  cover. 


3.     Double,  hard-rubber,  extension-neck  truss. 


4.     Hard-rubber  cross-body  truss. 


MECHANICAL  TREATMENT:  FEMORAL.       319 

Group  of  Trusses  for  Femoral  Hernia  {Con(imied). 


5.     Cross-body  truss  applied  for  femoral  hernia. 


6.    Chase  hard-rubber  truss. 


7.    French  truss  with  perineal  strap. 


8.    Foster  ratchet  truss,  hard  rubber. 


320  ABDOMINAL  HERNIA. 

Group  of  Trusses  for  Femoral  Hernia  ( Continued'), 


9.     Hood  truss  modified  for  femoral  hernia  on  left  side. 


10.     Double  hard-rubber  truss.     Made  for  inguinal  hernia ;  good  form  for  femoral. 


II.     French  truss,  leather  and  hard  rubber. 


12.     Extension  neck  hard-rubber  cross-body  truss. 


MECHANICAL    TREATMENT  :    FEMORAL.      321 

Group  of  Trusses  for  Femoral  Hernia  {Continued). 


13.    Turn-pad  hard-rubber  truss. 


14.    Chase  hard-rubber  femoral  truss. 


15.    Adjustable  French  truss,  hard  rubber. 


21 


16.    Elastic  truss. 


322 


ADOMINAL  HERNIA. 


One  of  the  most  important  points  in  selecting  a  truss  for 
femoral  hernia  is  that  its  retaining  pad  shall  be  small  enough 
to  tit  into  the  deep  femoral  space  without  impinging  upon  the 
spine  of  the  pubes  at  the  inner  side  or  upon  the  femoral  vessels 
at  the  outer  side  of  the  hernial  opening.     The  pad  should  be 

Fig.  175. 


Cross-body  bard-rubber  truss  witb  writer  pad.     Ajiplied  to  right  femoral  hernia. 

narrow,  not  too  long,  and  deep  enough  to  sink  well  into  the 
femoral  space  immediately  beneath  Poupart's  ligament;  having 
a  pressure  backwards  towards  the  thigh,  and  slightly  upwards. 
The  pad  shown  in  no.  4,  well  answers  this  purpose,  in  a  thin 
])crsnn,  and  has  been  much  used  on  them  b_v  the  autlior.  If, 
however,  the  jjatient  is  at  all   fat  it   is  not  sufficiently  deep. 


MECHANICAL  TREATMENT:   FEMORAL.      323 

A  small-sized,  but  prominent,  water  pad  (fig.  175)  is  very 
comfortable  in  these  cases,  but  should  be  used  only  on  those 
who  can  be  relied  upon  to  report  for  inspection  with  regularity, 

Fig.  176. 


,^Xii£:^iZj:*ti 


Cross-body  hard-rubber  truss  with  deep  pad,  for  femoral  hernia. 

owing  to  its  perishable  character.  These  pads  are  liable  to 
flatten  out  in  two  or  three  months'  wear  and  must  be  renewed. 
This  change  of  shape  is  particularly  dangerous  in  femoral 
hernia,  as  the  pressure  then  comes  upon  Poupart's  ligament  or 


324  ABDOMINAL  HERNIA. 

the  spine  of  the  pubes   and   is  held   away   from   the  hernial 
opening". 

Fig.  1/5  shows  applied,  a  form  of  truss  known  in  the  trade 
as  a  hard-rubber  cross-body  spring,  with  water  pad,  and  the 
combination  forms  a  most  excellent  truss  for  femoral  hernia. 
The  small  hard-rubber  pad  is  usually  preferred.  This  truss, 
when  properly  fitted,  can  be  worn  without  the  perineal  strap 
always  so  objectionable.  This  is  especially  referred  to  as  it 
is  kept  in  stock  by  nearly  all  truss  dealers  and  is  therefore 
readily  within  the  reach  of  most  practitioners.  As  found  in 
the  market,  it  is  designed  and  shaped  for  use  in  cases  of 
inguinal  hernia,  but  the  modifications  necessary  to  transform 
it  into  a  femoral  hernia  truss  are  easily  made.  In  selecting  a 
spring,  secure  one  wath  the  lightest  obtainable  pressure,  as 
femoral  hernia  never  requires  as  strong  pressure  for  its  reten- 
tion as  inguinal.  Then  select  the  smaller  pad,  as  the  one 
ordinarily  used  on  the  spring  is  too  large.  Such  a  pad  will 
usually  be  found  in  the  stock  of  the  dealer  on  the  youth's  size 
of  inguinal  truss,  and  can  be  easily  transferred  to  the  spring 
selected.  The  essential  changes  now  to  be  made  are  as 
follows : 

( 1 )  Changing  the  uniform  curve  across  the  front  of  the 
spring  so  that  the  pad  will  rest  flat  against  the  femoral  space. 
In  making  this  change  warm  thoroughly  the  rubber  that  covers 
the  spring  by  passing-  it  through  the  flame  of  a  spirit  lamp,  or 
by  putting  in  boiling  water,  and  then  bend  the  spring  with  the 
hands  or  pliers,  being  careful  not  to  bend  it  too  near  the  screw 
hole. 

(2)  In  the  shaping  of  the  spring  it  must  be  lengthened 
in  front  so  that  it  reaches  over  against  the  thigh.  In  the  gen- 
eral fitting,  the  method  of  making  a  diagram  described  under 
the  article  on  inguinal  hernia  must  be  followed  closely,  as  in 
this  wav,  better  than  any  other,  can  accurate  adjustment  be 
secured. 

The  cross-lxxly  spring  ]:)asses  around  tlie  hi])  op]:)osite  the 
affected  side  (as  shown  in  fig.  176),  just  above  the  trochanter 


MECHANICAL  TREATMENT:    FEMORAL.       325 

major,  in  very  nearly  the  position  occupied  by  the  inguinal 
hernia  truss ;  the  pad  is  placed  about  one  inch  lower,  its  lower 
edge  resting  upon  the  top  of  the  thigh.  The  spring  must  be 
about  half  an  inch  longer  in  front  than  when  used  for  inguinal 
hernia.  Some  of  the  trusses  known  as  the  French  (no.  7  of 
group)  or  German  style  (fig.  177)  are  very  good  for  femoral 
hernia.  The  two  styles  named  are  alike  except  that  the 
"  French "    are   lisfhter   in   construction   and   therefore   better 


Fig.    177. 


German  femoral  truss  applied.  Noie  that  direction  of  pressure  of  the  pad  is  towards 
the  spine  of  the  pubes  instead  of  into  the  femoral  space  and  towards  the  thigh.  Good  illustra- 
tion of  poor  truss-fitting. 

adapted  for  femoral  hernia.  If  this  truss  is  carefully  shaped 
by  the  diagram  method  it  can  usually  be  successfully  worn 
without  the  perineal  strap,  but  if  it  fails  to  maintain  an  exact 
position,  it  must  be  worn  even  though  irksome.  The  spring 
in  this  truss  does  not  pass  across  the  abdomen,  but  goes  around 
the  hip  of  the  affected  side.  The  English  form  of  this  type  is 
even  better  on  account  of  its  having  a  smaller  pad  (fig.  178). 
Springs  that  go  on  from  the  side  of  the  hernia,  like  the 
German,  French,  and  English  type,  are  better  suited  to  femoral 


326 


ABDOMINAL  HERNIA. 


than  to  inguinal  hernia,  as  the  curve  of  the  spring  brings  the 
direction  of  pressure  toward  the  thigh.  The  truss  known  as 
the  "  Chase  "  is  of  this  type  and  is  very  good.  Some  inguinal 
ti-usses  with  adjustable  pads  known  as  "  Common  Sense  "  and 
"  Excelsior  "  trusses, — very  similar  in  design, — are  also  good 
for  femoral  hernia  if  the  spring  pressure  is  sufficiently  dimin- 
ished.    One  is  shown  in  fig.  179. 

Fig.  178. 


Light  form  of  femoral  truss,  English  form.     {Macready.)     Illustration  of  good-fitting  truss. 

Several  manufacturers  have  modified  the  "  Hood  "  truss 
for  use  in  femoral  hernia,  but  in  my  own  hands  it  has  not 
proven  as  satisfactcjry  as  those  of  the  cross-body  type.  A 
truss  of  the  latter  type,  designed  by  me  many  years  ago,  is 
shown  in  fig.  180.  This  has  a  light  cross-body  spring,  the 
pad  being  supported  on  an  arm,  which  is  in  turn  attached 
to  the  spring  by  a  ratchet.     There  was  also  a  slot  in  the  face- 


MECHANICAL  TREATMENT:    FEMORAL.       327 

plate  of  the  pad  that  allowed  of  adjustment.  Between  the 
ratchet  and  the  slot  very  accurate  adjustment  of  the  pad  could 
be  obtamed. 


Fig. 


179. 


Adjustable  truss  made  for  inguinal,  also  suitable  for  femoral  hernia. 

The  Elastic  Truss  is  strongly  advised  against  as  being 
both  unreliable  and  uncomfortable.  The  author  has  seen  cases 
which  have  become  strangulated,  and  many  others  w^hich  have 
increased  in  severity  under  its  use.      Nor  has  the  author  ever 


328 


ABDOMINAL  HERNIA. 


seen  any  form  of  bandage  that  he  considered  in  the  least  degree 
safe.  While  waiting  for  a  suitable  truss,  if  one  is  not  at  hand, 
a    tight   bandage   with   a   moderately   hard   compress    in    the 

Fig.   i8o. 


De  Garnio  femoral  truss. 


femoral  space  is  somewhat  protective  and  should  be  used  only 
until  something  better  can  be  done. 

In  double  femoral  hernia  the  choice  of  truss  should  be 
between  the  "  Double  French  "  and  the  doul)le  hard-rubber 


MECHANICAL  TREATMENT:   FEMORAL. 


329 


truss  shown  in  no.  lo  of  group,  the  latter  with  small  pads 
being  very  much  preferred.  This  truss  is  made  for  inguinal 
hernia  and  the  curve  at  the  end  of  the  spring  must  be  modified 
in  order  to  have  the  pads  rest  fiat  upon  the  thigh.  It  seldom 
requires  the  thigh  strap  to  keep  it  in  position.  Fig.  i8i  shows 
a  truss  of  this  type  applied  to  an  inguinal  hernia  on  the  left  side 
and  femoral  on  the  right.     This  combination  has  proven  thor- 

FiG.  i8i. 


Woman  of  45  years  with  right  femoral  and  left  inguinal  hernia  retained  by  double  hard- 
rubber  truss  and  water  pads.  The  latter  are  for  temporary  use  only,  the  hard-rubber  pads 
being  better. 

oughly  satisfactory  in  many  cases.     A  smaller  pad  than  the  one 
shown  in  this  photograph  was  put  on  later. 

Irreducible  femoral  hernia  should  rarely  be  treated 
mechanically,  as  tlie  only  safety  in  these  cases  is  in  operation; 
in  some  cases,  however,  the  attending  circumstances  are  such 
that  operative  means  cannot  be  carried  out  and  some  substitute 
must  be  used.  If  the  hernia  is  small  a  concave  pad  may 
be  used,  preferably  on  the  cross-body  spring.  Usually  in 
such  cases  the  perineal  or  thigh  strap  is  necessary  to  keep  the 


330  ABDOMINAL  HERNIA. 

pad  in  place.  The  contents  of  irreducible  femoral  hernia  is 
almost  uniformly  omentum,  and  in  a  few  instances  the  author 
has  seen  its  absorption  occur  under  the  pressure  of  a  concave 
pad.  and  has  then  changed  to  the  convex  pad  generally  used  in 
femoral  hernia.  The  idea  advanced  in  some  of  the  older 
works  upon  this  subject  that  it  is  dangerous  to  make  truss 
pressure  upon  irreducible  omentum  has  been  too  often  dis- 
proven  in  the  experience  of  the  author  to  allow  of  anything  but 
the  most  emphatic  denial. 


CHAPTER  XVII. 
SURGICAL  CURE  OF  FEMORAL  HERNIA. 

The  history  of  the  operative  cure  of  femoral  hernia  is 
pecuHar,  in  that  works  upon  the  subject  have  repeatedly  stated 
that  owing  to  the  formation  of  the  so-called  "  ring  "  its  cure 
is  uncertain  and  improbable.  At  the  same  time  the  experience 
of  the  individual  operator  has  constantly  shown,  in  this  coun- 
try at  least,  that  if  he  be  careful  to  clear  the  femoral  opening 
of  sac  and  all  foreign  tissue  and  to  close  it  by  almost  any 
method,  a  cure  is  more  than  likely  to  result.  The  truth,  it 
would  then  seem,  is  that  the  objections  to  its  surgical  cure  have 
been  theoretical  rather  than  practical,  yet  this  has  led  to  the 
suggestion  of  many  different  methods  by  many  different 
operators. 

So  far  as  to  him  known,  the  report  of  the  author  before 
the  Surgical  Section  of  the  New  York  Academy  of  Medicine 
(Annals  of  Surgery,  August,  1905,  p.  209)  of  no  cases  oper- 
ated upon  by  one  method  and  by  the  same  operator,  is  the 
largest  that  has  been  made.  This  method  is  given  in  this 
work  to  the  exclusion  of  others,  not  because  it  was  original 
with  the  author,  but  because  of  its  simplicity,  ease  of  execu- 
tion, and  the  permanence  of  its  results.  It  was  first  done  by 
him,  on  March  4,  1890,  and  has  been  taught' to  his  classes  at 
the  New  York  Post-Graduate  Medical  School  and  Hospital 
since  that  date. 

The  cases  recorded  in  the  report  referred  to  were  met  with 
in  operating  upon  a  series  of  1,250  abdominal  herni?e.  The 
no  femoral  hernise  were  in  99  patients,  83  of  whom  were 
females  and  16  males.  Eighty-eight  patients  had  single  and 
1 1  had  double  femoral  hernia.  Of  the  single  hernias,  59  were 
on  the  right  side  and  29  on  the  left.  One  patient  had  double 
femoral  hernia  and  left  inguinal.     Three  had  double  inguinal 

331 


332  ABDOMINAL  HERNIA. 

and  single  femoral  hernia.  Two  had  single  femoral  and 
inguinal  hernia  on  the  same  side,  making  5  cases  who  had 
femoral  and  inguinal  hernia  on  the  same  side.  Six  had 
femoral  hernia  on  one  and  inguinal  on  the  opposite  side. 

In  28  patients,  strangulation  of  the  hernia  existed  at  the 
time  of  the  operation,  and  82  were  operated  upon  for  the 
cure  of  the  hernia.  The  ages  were,  4  under  ten  years;  6 
between  ten  and  twent}^  years;  18  between  twenty  and  thirty 
years;  34  between  thirty  and  forty  years;  15  between  forty 
and  fifty  years;  11  between  fifty  and  sixty  years;  5  between 
sixty  and  seventy  years ;  5  between  seventy  and  eighty  years ; 
I  over  eighty  years.  The  youngest  patient  was  eight  years  of 
age  and  the  oldest  eighty-one  years.  The  latter  was  operated 
upon  in  a  private  house,  in  the  middle  of  the  night,  for  femoral 
hernia  of  enormous  size  that  had  existed  for  thirty  years  and 
which  had  been  strangulated  for  six  hours.  She  lived  nine 
years  after  the  operation,  during  which  time  she  wore  no  truss 
and  had  no  recurrence. 

Mortality. — In  the  entire  number  only  one  death  has 
occurred,  and  that  was  an  old  woman  of  seventy  years,  who 
had  suffered  from  strangulated  hernia  for  three  days,  during 
which  time  she  had  been  subjected  to  the  most  violent  attempts 
at  reduction.  Perforation  of  the  bowel  was  found,  and,  owing 
to  the  moribund  condition  of  the  patient,  the  intestine  was 
fastened  in  the  wound  and  freely  opened.  She  died  of  exhaus- 
tion twenty-four  hours  later. 

Recurrences. — In  one  case  there  was  recurrence  three 
weeks  after  the  operation  from  violent  vomiting  due  to  acute 
indigestion.  This  case  was  re-operated  upon  eight  months 
afterwards,  and  has  remained  cured  three  years.  One  patient, 
a  man,  who  had  double  inguinal  and  right  femoral  hernia,  was 
supposed  to  have  a  recurrence  of  the  femoral  hernia.  Upon 
re-operating,  the  protrusion  wa*5  found  to  be  subperitoneal  fat 
that  had  slipped  through  under  Poupart's  ligament,  but  no 
hernial  sac  had  formed.  In  one  other  case,  believed  to  be 
identical  with  the  one  just  narrated,  a  woman  of  thirty-five 


SURGICAL  CURE:  FEMORAL.  333 

years  had  a  small  swelling  in  the  femoral  region  nine  months 
after  operation.  A  light  truss  was  applied  and  worn  one  year, 
and  she  has  now  been  five  years  without  support  and  no  pro- 
trusion. It  is  believed  that  this  also  was  a  small  protrusion  of 
subperitoneal  fat,  and  absorption  was  produced  by  truss  press- 
ure. I  have  never  seen  a  femoral  hernia  cured  by  truss 
pressure,  no  matter  how  young  the  patient  nor  how  small  the 
protrusion. 

One  woman  of  seventy-five  years  of  age  had  a  recurrence 
within  eight  months  of  the  operation,  and,  so  far  as  I  know, 
this  is  the  only  actual  recurrence.  By  far  the  greater  number 
of  these  cases  have  been  traced  and  the  permanence  of  the  cure 
ascertained.  Three  cases  operated  upon  were  recurrent  follow- 
ing some  previous  operation,  the  character  of  which  is 
unknown.  All  of  these  recurrent  cases  have  remained  cured 
for  more  than  four  years.  Two  cases  had  by  mistake  been 
operated  upon  for  inguinal  hernia,  when,  in  reality,  femoral 
hernia  existed,  and  it  is  a  rather  remarkable  fact  that  both 
were  done  by  operators  noted  in  other  lines  of  surgical  work. 

Contents. — Contents  of  the  hernise  were  in  most  instances 
intestine  or  omentum,  or  both.  In  one  instance  a  small  and 
unhealthy  ovary  was  found  in  the  sac.  In  two  cases  of 
strangulation  with  quite  acute  symptoms,  appendices  epiploicae 
were  found  strangulated.  In  these  cases  the  bowel  itself  was 
held  firmly  against  the  femoral  opening,  but  the  lumen  of  the 
intestine  was  not  constricted.  Cysts  in  or  around  the  sac  were 
found  in  4  cases. 

In  one  case,  the  daughter  of  a  well-known  physician, 
strangulation  was  coincident  with  the  first  protrusion  of  the 
hernia.  In  stepping  from  a  railroad-car,  the  step  being  much 
higher  than  she  had  estimated,  a  hernia  was  forced  through 
the  femoral  canal,  and  urgent  symptoms  at  once  presented. 

The  safety  and  comfort  of  the  patient  demand  that  every 
case  of  femoral  hernia,  whether  reducible  or  irreducible,  shall 
be  cured  unless  there  is  something  in  the  condition  of  the 
patient  that  positively  contraindicates  an  operation.    Its  peculiar 


334 


ABDOMINAL  HERNIA. 


anatomical  surroundings  make  femoral  hernia  an  unsually  dan- 
gerous condition,  and  render  its  successful  treatment  by 
mechanical  means  uncertain  as  well  as  attended  by  discomfort. 
On  the  other  hand,  viewed  from  the  surgical  side  it  is  consid- 
ered the  safest  of  all  hernise  for  operative  cure ;  the  operation 
is  easier  of  execution  and  it  is  fully  as  permanent  in  its  results 
as  that  done  on  any  other  form  of  hernia.     The  danger  in  the 

Fig.  182. 


Showing  location  and  direction  of  incision  for  femoral  hernia  operation. 

hands  <jf  a  c|ualified  surgeon  in  an  uncomplicated  case  would 
actually  seem  to  be  limited  to  whatever  attends  the  gi\'ing  of 
the  aUcTSthetic.  The  preparation  of  the  patient,  and  for  the 
operation,  should  l^e  as  carefully  made  as  for  any  other 
abdrjminal  operation. 

Operation. — The  incision  for  the  operation  here  described 
should  1)e  between  two  and  three  inches  long,  parallel  with 
and  to  the  inner  side  of  tlie  femoral  vessels  (fig.   182).     The 


SURGICAL  CURE:  FEMORAL. 


335 


upper  angle  of  the  wound  should  be  well  up  over  Poupart's 
ligament  and  extend  down  over  the  saphenous  opening.  Many 
times  the  line  of  separation  between  the  superficial  fascia  and 
the  deep  transversalis  fascia,  that  has  been  pushed  down  in 
front  of  the  peritoneum  by  the  hernia,  will  be  so  distinctly  seen 
as  to  lead  the  operator  to  feel  that  he  has  the  true  sac.     On 

Fig.   1 8::. 


Showing  protrusion  under  Poupart's  ligament.     The  femoral  vessels  are  to  the  outer  side  of 
the  sac.    The  sac  should  have  been  shown  with  smaller  neck. 


cutting  through  this,  however,  he  will  come  upon  the  subperi- 
toneal fat  (sometimes  mistaken  for  adherent  omentum)  and 
then  reach  the  bluish-white,  true  hernial  sac.  As  in  other  loca- 
tions when  the  true  sac  is  opened,  there  is  almost  uniformly 
found  evidence  of  the  normal  abdominal  fluid  and  the  shiny 
surface  characteristic  of  peritoneum. 

When   the    skin    and   the    superficial    fascia   are    incised, 
usually  the  sac  and  its  subperitoneal  fat  will  come  into  the 


336 


ABDOMINAL  HERNIA. 


wound,  appearing-  like  an  encysted  lipoma  (fig.  183),  and, 
before  separating  the  sac,  it  is  best  that  this  entire  mass  should 
be  lifted  out  of  its  bed  by  thumb  forceps  and  blunt  dissection, 
so  that  its  neck  where  it  passes  under  Poupart's  ligament  shall 
be  entirely  free  from  its  surroundings.  By  traction  on  the  sac 
(fig.  184)  and  its  superimposed  fat,  this  neck  may  not  only  be 
freed,  but  it  will  be  materially  lengthened,  so  that  when  it  is 

Fig.  184. 


Sac  forcibly  drawn  down  while  being  ligated  and  cut  away.    This  after  examining  its  interior 
to  see  that  no  adhesions  exist. 

finally  ligated  and  cut  off  it  will  retract  within  the  abdominal 
cavity,  leaving  the  femoral  canal  free  of  foreign  tissue.  This 
is  absolutely  essential  to  the  subsequent  permanent  cure  of  the 
case.  It  must  ])c  borne  in  mind  that  extreme  traction  might 
easily  bring  into  the  operative  field  either  an  angle  of  the  blad- 
der wall  to  the  inner  side,  or  the  deep  epigastric  vessels  upon 
the  upper  surface  of  the  sac.  Both  of  these  have  been  seen  in 
this  operation. 


SURGICAL  CURE:  FEMORAL. 


337 


The  sac  should  be  opened,  and  where  omentum  is  found 
adherent  it  should  be  carefully  ligated,  cut  away,  and  its  stump 
reduced  to  the  abdominal  cavity.  Adherent  intestine  will  rarely 
be  found,  but  where  it  is,  the  adhesions  must  either  be  broken 
up,  or,  if  too  firm,  the  adherent  part  may  be  cut  out  of  the 
sac  and  left  attached  to  the  bowel.  When  in  doubt,  the  latter 
method  is  by  far  the  safer. 

Fig.  185. 


Showing  sutures  of  kangaroo  tendon  passing  through  Poupart's  ligament  above  and  through 
all  tissues  to  periosteum  of  ramus  of  pubes  below. 

The  sac,  having  been  entirely  freed  of  its  contents,  is  tied 
off  as  high  up  as  possible  w^hile  it  is  being  forcibly  drawn  down 
by  an  assistant.  Great  care  must  be  used  to  insure  the  perfect 
freedom  of  the  neck  of  the  sac  from  protruding  bowel  or 
omentum  while  the  ligature  is  being  placed.  After  tying  with 
strong  catgut  (a  double  strand  of  no.  2  plain  is  preferred), 
pass  the  needle,  which  has  been  previously  threaded  wnth  it, 
through  the  neck  of  the  sac  and  tie  again.     This  gives  a  double 

22 


338 


ABDOMINAL  HERNIA. 


ligature,  anchored  by  perforation  between  the  two,  which  pre- 
\-ents  shpping  off. 

\\''hen  the  sac  is  cut  away  the  stump  should  be  examined 
to  be  sure  that  no  bleeding-  vessels  remain,  and  not  until  then 
should  the  ends  of  the  ligature  be  cut,  after  which  the  stump 
usually  retracts  within  the  abdomen.     If  this  is  prevented  by 

Fig.  1 86, 


^jhj^ 

' 

^Km 

^W|M|^WWBIB^Brr^' 

\     .'^Sf! 

\  '^^W 

'  '''^m 

\: 

w- 

c- 

Showing  depression  of  Poupart's  ligament  to  ramus  of  pubes  by  sutures  tied  down, 

connective  tissue  which  has  not  been  broken,  it  should  be  care- 
fully pushed  back,  leaving  the  femoral  opening  absolutely  free. 
This  opening  is  closed  in  the  following  manner  by  good 
sized  kangaroo  tendon  threaded  in  a  strong  blunt  needle  (fig. 
185).  Press  the  end  of  the  finger  firmly  into  the  femoral  open- 
ing under  Poupart's  ligament,  and  pass  the  needle  through  the 
ligament  upon  the  finger-point.  This  perforation  should  be 
well  towards  the  outer  side  of  the  canal  and  close  to  the 
femoral  vein.    The  operator  should  assure  liimself,  by  pressure 


SURGICAL  CURE:  FEMORAL. 


339 


of  the  finger  against  the  ramus  of  the  pubes,  that  the  vessels  are 
out  of  the  way,  and  then  pass  the  point  of  the  needle  fully  down 
to  the  periosteum  of  the  pubic  bone,  taking  up  all  tissues  over 


Blunt  needle  used  in  putting  sutures  in  place. 


it.     This  constitutes  the  first  stitch,   but  should  not  be  tied 
until  the  others  are  in  place.      Sutures  should  then  be  placed  in 

Fig.   i88. 


Double  reducible  femoral  hernia  in  a  woman  of  60  years.    Left  side  does  not  show,  but  was 
nearly  the  size  of  a  hen's  egg.    Swelling  above  pubes  is  due  to  subcutaneous  fat. 

the  same  manner  every  quarter  of  an  inch  apart  until  near  the 
spine  of  the  pubes  (fig.  i86).  Usually  three  or  four  will  com- 
pletely close  the  femoral  opening. 


340 


ABDOMINAL  HERNIA. 


When  tied  down  and  the  ends  cut  moderately  close 
the  fascia  should  be  closed  in  by  plain  catgut,  to  avoid  a 
pocket  in  the  tissues  that  otherwise  may  result,  and  the  skin 
may  then  be  closed  b}^  buried  sutures  of  the  same.  I  have 
usually  covered  the  wound  by  collodion  and  a  compress  of 
sterilized  gauze  held  in  place  by  a  figure-of-eight  bandage.  In 
ten  days  the  dressings  are  changed  and  a  bandage  for  tem- 


FlG.  189. 


Same  case  as  shown  in  fig.  188;  side  view. 

porary  support  is  applied.  If  healing  has  been  complete,  the 
patient  is  allowed  to  sit  up  on  the  tenth  and  leave  the  house  on 
the  fourteenth  day  after  the  operation. 

The  bandage  used  after  the  first  dressing  consists  of  a 
pelvic  belt,  of  three  thicknesses  of  canton  flannel,  with  a  com- 
press rjf  gauze  over  the  former  site  of  the  hernia,  and  a  perineal 
strap  to  prevent  its  slipping  up.  This  is  to  be  worn  for  four 
weeks.  Neither  truss  or  other  permanent  support  should  be 
worn. 


SURGICAL  CURE:  FEMORAL. 


341 


As  it  is  not  an  uncommon  occurrence  tO'  have  both  inguinal 
and  femoral  hernia  on  the  same  side,  it  is  deemed  best  to  say 
a  few  words  regarding  the  combined  operations:  A  single 
incision  will  answer  every  purpose,  but  it  should  be  a  little 
longer,  beginning  over  the  centre  of  the  inguinal  canal  and 
curving  downward,  passing  to  the  inner  side  and  parallel  with 
the  femoral  vessels  to  the  saphenous  opening;  this  gives  easy 
access  to  both  canals.    The  femoral  sac  should  be  removed,  the 

Fig.  190. 


Same  case  as  shown  in  fig.  188,  six  weeks  after  double  operation. 

canal   closed   as   already  described,   then   the   inguinal  hernia 
should  be  operated  upon  as  though  no  complication  existed. 

Suture. — The  idea  that  the  suture  in  the  operation 
described  would  make  too  much  pressure  on  the  femoral  vein 
is  a  very  natural  one,  but  it  is  believed  that  with  ordinary  care 
this  will  never  occur.  At  least  in  the  cases  presented  no  indi- 
cation of  undue  pressure  has  ever  been  observed.  There  has 
been  nO'  change  in  the  technique  of  this  operation  during  the 
fifteen  years  of  its  use  by  me,  except  in  the  suture  material. 


342 


ABDOMINAL  HERNIA. 


In  the  first  22  operations,  No.  10  braided  silk  was  used 
for  closing  the  femoral  opening.  In  3,  silkworm  gut  was 
employed ;  but  in  the  last  85  cases,  i.e.,  since  November  20, 
1896,  kangaroo  tendon  has  been  used  exclusively.  There  can 
be  no  question  at  the  present  day,  it  would  seem  to  me,  that  the 
last-named  substance  approaches  more  nearly  than  any  other 

Fig.  191. 


Femoral  hernia  of  unusual  type,  due  to  cutting  of  Poupart's  ligament  in  operation  for  stran- 
gulated hernia.     Notice  broad  base  of  tumor.     Woman  38  years  old,  4  months  pregnant. 


the  ideal  suture  for  this  purpose.  The  deep  sutures  have  been 
placed  by  a  blunt  needle  with  handle  (fig.  187).  (It  is  be- 
lieved that  the  use  of  a  sharp  needle,  or  even  a  blunt  needle  in 
a  holder,  is  attended  by  considerable  danger  of  injury  to  the 
femoral  vein.) 

This  operation  answers  equally  well  in  femoral  hernia;  of 
either  large  or  small  size,  and  has  frequently  been  used,  as  in 


SURGICAL  CURE:  FEMORAL.  343 

figs.  1 88,  189  and  190,  for  enormous  protrusions  on  one  side 
and  a  small  hernia  on  the  other  on  the  same  patient.  Follow- 
ing operations  for  strangulated  femoral  hernia  it  can  be  used 
almost  as  quickly  as  the  parts  can  be  closed  without  any  cura- 
tive method,  and  it  insures  the  patient  against  subsequent  disas- 
ter. In  only  one  patient  have  I  been  unable  to  make  this 
closure,  and  this  was  the  case  in  which  it  was  necessary  to  leave 
the  bowel  open.  In  giving  this  method  and  excluding  the 
many  others  that  have  been  suggested  I  fully  realize  that  I 
open  wide  the  door  of  criticism,  but  it  has  been  my  effort 
throughout  this  work  to  simplify,  as  far  as  possible,  the  opera- 
tive procedures  advised. 

I  am  confident  that  the  circular  suture,  used  by  some  good 
and  experienced  operators,  which  includes  Poupart's  ligament 
above  and  the  tissues  covering  the  ramus  of  the  pubes  below, 
will  accomplish  the  same  end.  The  essential  element  of  suc- 
cess is  in  clearing  the  femoral  opening  of  sac  and  all  other 
foreign  tissues.  On  the  contrary,  I  have  no  confidence  what- 
ever in  the  so-called  plastic  operations  which  rely  for  success 
upon  the  transplanting  of  muscle  or  tendon.  Nor  have  I  confi- 
dence in  those  which  attempt  to  close  the  saphenous  opening  in 
the  fascia  of  the  thigh.  The  origin  of  the  hernia  is  at  the  peri- 
toneal surface  of  the  abdominal  wall  and  here  its  remedy 
should  be  applied. 


CHAPTER  XVIII. 
UMBILICAL  HERNIA. 

For  reasons  stated  later,  I  have  not  classified  hernia  into 
the  umbilical  cord,  which  is  really  a  malformation,  with  umbili- 
cal hernia,  as  done  by  most  authors. 

Umbilical  hernia  is  a  protrusion  of  any  of  the  abdominal 
contents  through  the  umbilical  ring.  The  cases  may  be  divided 
into  those  of  infancy  and  those  of  adult  life.  By  "  infancy  " 
it  is  intended  to  refer  to  children  under  five  years  of  age.  Even 
this  division  is  not  based  upon  any  anatomical  or  pathological 
consideration,  but  is  used  because  in  infancy  these  hernias  can 
be  cured  by  purely  mechanical  means,  while  in  the  adult  a  cure 
never  results  without  surgical  interference.  The  division  is 
therefore  merely  one  of  convenience. 

Umbilical  hernia  constitutes  about  S}4.  per  cent,  of  all 
hernise.  Up  to  the  tenth  year  of  age  it  is  about  equally  divided 
between  the  sexes,  but  in  later  life  it  is  more  frequent  in  the 
female  in  the  proportion  of  2.7  to  i. 

In  adult  life  the  umbilicus  is  three-quarters  of  an  inch 
above  the  highest  point  of  the  iliac  crest,  and  opposite  the  disk 
between  the  third  and  fourth  lumbar  vertebras.  At  two  years 
of  age  it  occupies  the  exact  middle  point  of  the  body  measured 
from  head  to  foot.  Earlier  it  is  below  and  later  it  is  above 
this  point.  In  the  fcetus  it  is  close  to  the  pubes.  It  is  the  final 
point  of  closure  of  the  lateral  abdominal  walls  and  surrounds 
the  vessels  of  the  cord  which  become  obliterated  at  birth. 
These  obliterated  vessels  form  four  strong  bands  of  fibrous 
tissue  which  pass  through  the  umbilical  ring  and  end  in  the 
umbilical  scar.  The  umbilical  vein  descends  from  above,  the 
two  umbilical  arteries  and  urachus  from  below;  the  urachus 
holding  the  umbilicus  firmly  against  the  lower  margin  of  the 
ring. 

344 


UMBILICAL  HERNIA.  345 

The  umbilical  ring  is  the  opening  in  the  linea  alba  for  the 
transmission  of  the  nutrient  vessels  before  birth,  and  if  normal 
should  surround  closely  the  remains  of  the  cord  when  that 
sloughs  off.  This  ring  is  occupied  by  the  obliterated  vessels 
and  a  small  amount  of  fat.  The  peritoneum  in  this  region 
is  thin  and  firmly  adherent,  especially  above  the  umbilicus.  The 
transversalis  fascia,  fortified  by  additional  fibres  known  as  the 
umbilical  fascia,  is  beneath  the  linea  alba.  Defects  in  closure 
of  this  ring  may  be  anywhere  from  a  large  cleft  in  the  muscular 
wall,  constituting  so-called  congenital  umbilical  hernia,  to  a 
mere  weakness.  These  defects  are  most  frequently  found 
above  the  navel. 

The  parts  within  the  abdomen  most  frequently  involved 
in  umbilical  hernia  are  the  omentum,  the  large  and  small 
intestine.  The  greater  omentum  starts  from  the  lower  border 
of  the  stomach,  descending  over  the  small  intestine,  forming 
a  double  fold  of  peritoneum.  It  passes  downward  a  variable 
distance,  folds  upon  itself,  and  returns  to  envelop  the  transverse 
colon,  back  of  which  it  is  continued  and  attached  to  the 
posterior  abdominal  wall,  forming  the  mesocolon.  According 
to  Dr.  Zabe  {Thirteenth  International  Congress,  Paris,  1900), 
in  umbilical  protrusions,  traction  upon  the  omentum  impedes 
the  motions  of  the  stomach,  and  depresses  the  arch  of  the 
colon,  resulting  in  an  enteroptosis.  Eventually  the  stomach 
has  a  tendency  to  become  vertical  and  the  prolapsed  intestine 
becomes  stenosed,  causing  what  he  aptly  calls  "  hernial 
dyspepsia." 

Cause. — It  does  not  require  deep  research  to  discover  the 
predisposing  cause  of  hernia  in  this  region.  The  opening  in 
the  linea  alba,  for  the  transmission  of  the  prenatal  vessels  of 
nutrition,  is  filled  in  after  birth  by  the  remains  of  those  vessels 
and  fibrous  or  cicatricial  tissue.  Undoubtedly  this  is  the  weak- 
est point  in  the  whole  abdominal  wall,  but  from  its  location  it 
is  not  subjected  to  as  great  a  strain  as  those  parts  lower  down. 
In  conditions  of  marked  obesity,  or  when  intra-abdominal 
growths  exist,  this  umbilical  ring  is  subjected  to  great  and  con- 


346  ABDOMINAL  HERNIA. 

stant  strain,  and  it  then  stretches  or  even  occasionally  tears, 
allowing  the  contained  viscera  to  protrude. 

Frequent  pregnancies,  by  repeated  over-distention  of  the 
muscular  w^all,  lead  to  the  common  occurrence  of  umbilical 
hernia  in  women  between  forty  and  fifty  years  of  age.  Women 
who  at  this  period  of  life  have  put  on  an  inordinate  amount  of 
fat  are  especially  liable  to  it.  In  fact,  the  latter  is  believed  to 
be  a  far  more  potent  cause  than  pregnancy.  With  the  great 
increase  of  fat  there  is  frequently  a  corresponding  degeneration 
of  the  muscular  tissue,  so  that  with  increased  intra-abdominal 
pressure  there  is  decreased  power  of  retention.  Further  than 
this,  such  women  are  very  liable  to  fatty  degeneration  of  the 
heart  muscle  and  are  therefore  dangerous  patients  upon  whom 
to  do  extensive  surgical  work. 

Umbilical  hernia  not  uncommonly  results  from,  or  may 
form  a  complication  of,  acites,  the  fluid  forming  in  the  abdom- 
inal cavity  being  forced  through  the  umbilical  ring  as  well  as,  in 
some  cases,  through  both  inguinal  canals. 

In  infancy  umbilical  hernia  is  believed  to  result  almost  uni- 
formly from  defective  closure,  in  the  median  line,  of  the  lateral 
walls  of  the  abdomen.  This  predisposing  cause  is  also  thought 
to  account  for  many  cases  occurring  in  thin  people  whose 
abdomens  have  not  been  subjected  to  abnormal  distention.  The 
defective  muscular  and  tendinous  structures  about  the  navels  of 
many  children  is  quite  apparent ;  in  some  instances  children 
reach  adult  life  safely  only  to  develop  hernia  later,  and  in 
others  the  tissues  so  harden  and  develop  as  to  gain  for  them 
comjjlete  immunity.  Given  this  defective  structure,  it  is 
usually  easy  to  find  in  crying,  coughing,  or  constipation  an 
immediate  cause.  The  last  named  is  thought  to  be  most  com- 
mon. I  cannot  endorse  the  view  of  some  authors  that  there 
are  in  these  cases,  as  in  tlie  congenital  type  of  inguinal  hernia,  a 
preformed  sac  that  has  persisted  during  the  years  preceding 
the  occurrence  of  hernia. 

Size  and  Form. — In  tlie  infant  umbilical  liernia  usually 
presents  as  a  circular  swelling  at  the  umbilical  ring,  varying  in 


UMBILICAL  HERNIA. 


347 


size  from  the  end  of  the  httle  finger  to  that  of  the  fist.  The 
photograph  shown  in  fig.  192  represents  a  common  size  as  met 
with  in  practice. 

The  form  of  the  tumor  in  infants  is  ahnost  always  circular 
and  projects  from  the  body  with  little  tendency  to  dissect  up 
the  adjoining  skin,  as  in  the  cases  occurring  in  the  adult,  even 
though  the  hernia  attains  unusual  size.  Umbilical  hernia  in 
infancy  is  rarely  irreducible.     In  the  adult  this  form  of  hernia 

Fig.  192. 


Small  umbilical  hernia  in  a  child  3  years  old.    Present  since  early  infancy  ;  truss  constantly 
worn,  with  little  indication  of  cure. 

may  become  a  tumor  of  enormous  proportions.  I  saw  in  con- 
sultation several  years  since  a  case  where  the  largest  part  of  the 
tumor  measured  forty-two  inches  in  circumference  and  thirty- 
four  inches  at  its  neck.  The  woman,  who  was  about  sixty-five 
years  old,  carried  this  protrusion  in  a  bag  arrangement  made 
of  canvas  supported  by  suspenders  over  the  shoulders. 

The  form  of  the  hernia  in  the  adult  is  very  irregular  and 
influenced  by  the  contents  of  the  sac  and  by  resisting  bands 
encountered  while  passing  through  the  umbilical  ring.     The 


348 


ABDOMINAL  HERNIA. 


tough  bands,  the  remains  of  the  umbihcal  vessels,  may  divide 
the  tumor  into  several  parts,  giving-  it  a  lobulated  appearance 
(figs.  193,  194  and  195).  These  tumors  become  pendulous 
and  in  some  instances  hang  well  down  over  the  pubes  towards 
the  knees. 

Fig.  193. 


Enormous  irreducible  umbilical  hernia,  containini?  wliole  of  transverse  colon  and  large 
amount  of  small  intestine,  all  adherent.  Very  little  omentum  present.  Dark  spots  to  right 
of  tumor  are  ulcerations  through  coverings,  allowing  leakage  of  abdominal  fluid. 


The  coverings  of  umljilical  hernia  are  the  skin,  superficial, 
deep,  and  suljserous  fascia,  and  the  peritoneum.  The  layers  of 
fasci?e  are  so  thin  as  to  be  indistinguishable,  and  an  incision 
through  the  overlying  skin  will  almost  always  open  the  peri- 
toneum, owing  to  the  intimate  union  between  the  outer  and 
inner  coverings.  When  it  is  considered  that  intestine  is  com- 
monly adherent  to  the  peritoneal  surface,  tlie  importance  of 


UMBILICAL  HERNIA. 


349 


making  the  incision  well  to  one  side  of  the  tumor  will  be 
realized. 

Contents  of  Sac. — In  infancy  the  hernial  sac  seldom  con- 
tains anything-  but  omentum  or  intestine,  but  in  the  adult  it 
may,  like  inguinal  hernia,  contain  any  of  the  abdominal  or 

Fig.   ig4. 


Side  view  of  previous  case. 


pelvic  contents.  The  omentum  or  colon  are  most  frequently 
present.  In  one  case  I  found  the  fimbriated  extremity  of  the 
fallopian  tube  adherent  outside  of  the  umbilical  ring. 

Condition. — Omentum,  ordinarily  the  first  to  protrude  in 
umbilical  hernia,  readily  becomes  adherent.  In  this  position  it 
increases  in  bulk,  both  by  additions  from  inside  the  abdomen 
and  by  growth  of  that  part  which  is  retained  outside.  This 
hypertrophy  is  doubtless  due  to  pressure  at  the  hernial  opening 


350 


ABDOMINAL  HERNIA. 

Fig.  195. 


.Man  of  45  years.    Enormous  umbilical  hernia.    Partially  reducible. 

Fig.  196. 


I 'riiliilical  hernia  (rc-flucilile)  in  woman  wciKhinu;  abdut  200  lb. 


UMBILICAL  HERNIA. 

Fig.  197. 


351 


Irreducible  umbilical  hernia  in  a  woman  weighing  229  lb.  Hernia  is  larger  than  the  fist, 
but  does  not  show  on  account  of  the  thickness  of  overlying  fat.  The  protrusion  is  almost 
entirely  to  the  right  of  the  umbilicus. 

Fig.  198. 


Man  45  years  of  age.     Umbilical  hernia  irreducible  for  six  years. 


352 


ABDOMINAL  HERNIA. 


upon  the  neck  of  the  protrusion,  thereby  impeding  venous  cir- 
culation, while  the  arteries  continue  to  pump  blood  into  the 
parts. 

Fig.  199. 


Hfi'ti'Srm-";-"^"-^ 


Before  operation.    Drawing  showing^  the  femoral  and  umbilical  hernise,  with  practically  no 
indication  of  the  presence  of  the  other  hcrniae.     '^Dainbridge.) 

Following  the  omental  prcjtrusion  the  transverse  colon  is 
quite  likely  to  descend  and  a  few  loops  of  small  intestine  are 
pretty  sure  to  be  ])r<;sent  in  hernia  of  large  size.     The  sacs  of 


UMBILICAL  HERNIA. 


353 


Fig.  200. 


I      t 


Drawing  showing  conditions  found  in  central  line  of  abdomen  at  time  of  operation. 
7.  Hernia  epigastrica.  2.  Umbilical  entero-epiplocele.  3.  Para-umbilical  epiplocele.  4.  Para- 
umbilical entero-epiplocele.     5.  Lipoma  with  small  epiplocele  underneath.     (£ai>idridg-e.) 


23 


354  ABDOMINAL  HERNIA. 

large  umbilical  hernia  seem  especially  liable  to  localized  inflam- 
mation; this  extending  to  the  contents  results  in  a  matting 
together  and  soon  causes  the  hernia  to  become  irreducible. 

Symptoms. — There  is  little  trouble  in  making  a  diagnosis 
of  umbilical  hernia.  In  the  infant  a  reducible  tumor  in  the 
umbilical  region  may  be  accepted  as  an  umbilical  hernia.  An 
error  that  is  sometimes  made  is  in  mistaking  an  unusually  long 
and  prominent  navel  for  an  umbilical  hernia.  Several  instances 
of  this  kind  have  been  seen  by  the  author;  one  in  a  girl  of 
fourteen,  brought  to  him  from  a  distant  state.  She  had  worn 
a  truss  since  one  year  old  for  supposed  umbilical  hernia.  No 
hernia  was  found,  and  from  the  history  elicited  it  was  confi- 
dently believed  that  none  had  ever  been  present.  The  navel, 
about  the  size  of  an  adult  little  finger,  projected  fully  three- 
quarters  of  an  inch  from  the  abdominal  surface.  There  was  no 
protrusion  inside  of  this  loose  skin.  Several  similar  cases  have 
been  seen  in  the  hernia  clinic  at  the  Post-Graduate  Hospital. 

Aside  from  the  tumor  there  are  few  symptoms  attending 
an  umbilical  hernia  in  infancy  or  early  childhood.  In  the  adult, 
however,  it  is  frequently  accompanied  by  considerable  local 
pain,  and  gastro-intestinal  symptoms  are  marked.  Nausea  and 
even  vomiting  may  be  produced  when  there  is  no  strangulation, 
and  this  is  believed  to  be  due  to  traction  upon  the  stomach. 

In  the  larger  hernias  obstinate  constipation,  eventually  ter- 
minating in  intestinal  obstruction  and  death,  results  from  the 
crip'pled  condition  of  the  bowel.  Common  types  of  this  form 
of  hernia  as  seen  in  the  adult  are  shown  in  figs.  196,  197  and 
198.  The  case  of  Bainbridge  {The  Posf-Gradiiatc,  February, 
1905)  is  of  special  interest  in  showing  the  defective  closure 
throughout  the  median  line  of  the  abdominal  wall.  In  this 
case  there  existed  five  hernic-e  in  the  median  line  besides  a 
femoral  hernia  (figs.  199  and  200). 


CHAPTER  XIX. 

•     MECHANICAL  TREATMENT  OF  UMBILICAL 

HERNIA. 

The  discussion  of  the  treatment  of  umbiHcal  hernia 
naturally  divides  itself  into  a  consideration  of  methods  which 
are  palliative  or  mechanical,  and  methods  which  are  curative  or 
surgical;  this  again  divides  the  cases  into  those  occurring  in 
infancy  and  very  early  childhood,  which  are  readily  cured  by 
palliative  means,  and  those  occurring  in  adult  life,  when  a 
cure  is  never  obtained  except  by  surgery. 

Treatment  of  Umbilical  Hernia  in  Infancy, — The  cure  of 
small  umbilical  protrusions  in  early  infancy  is,  in  some 
instances,  accomplished  independently  of  the  family  doctor. 
The  grandmother  has,  on  discovering  the  condition,  made  a 
compress  of  a  half  dollar,  if  particularly  wealthy,  but  more 
frequently  of  a  button-mold,  and  has  held  it  in  place  by  a  belly- 
band  for  two  or  three  months,  and  the  hernia  has  been  cured 
v/ithout  the  doctor  ever  having  known  that  it  existed.  This 
illustrates  by  what  simple  methods  umbilical  hernia  may  be 
cured  in  the  new-born  child,  and  makes  it  seem  strange  that  in 
the  adult  its  cure  can  never  be  obtained,  except  by  a  surgical 
operation. 

It  has  been  my  habit  for  many  years,  both  in  my  clinical  and 
private  work,  to  put  no  trusses  on  babies  under  one  year  of  age, 
or,  in  other  words,  before  they  begin  to  walk.  They  have,  with 
rare  exceptions,  been  treated  by  a  compress  over  the  navel, 
held  in  place  by  one  or  more  strips  of  zinc  oxide  plaster.  The 
compress  has  sometimes,  and  preferably,  been  a  hard-rubber 
umbilical  pad,  such  as  is  found  on  infant  trusses;  sometimes 
it  has  been  a  wooden  button-mold,  and  many  times  a  roll  of 
gauze  wrapped  about  by  plaster  with  the  sticky  side  out  so 
that  it  would  stay  just  where  placed.     Fine  cork  with  its  edges 

355 


356 


ABDOMINAL  HERNIA. 


beveled  forms  an  excellent  compress.  The  hernia  should  be 
reduced,  the  compress  placed  over  the  navel,  and  inch-v\^ide 
strips  of  zinc  oxide  plaster  placed  across  it  at  different  angles, 
the  ends  extending  about  two-thirds  of  the  distance  around  the 
body.  Two  strips  are  usually  sufficient  and  many  times  one 
will  answer  every  purpose.  It  is  not  M^ell  to  have  the  plaster 
meet  in  the  back,  as  there  is  then  no  allowance  for  abdominal 
distension.  I  have  seen  a  child  who  had  inguinal  hernia  pro- 
duced by  plaster  applied  in  this  manner  and  the  consequent 

Fig.  20I. 


Dr.  S.  W.  Kelley's  combination  of  hard-rubber  plate  and  plaster,    i.  Hard- rubber  plate.    2.  Plate 
with  plaster  attached.    3.  Plaster  unbuttoned  and  plate  turned  back. 


forcing  of  the  abdominal  contents  into  the  lower  abdomen. 
This  dressing  should  be  removed  once  a  week  and  renewed 
after  the  parts  have  been  bathed. 

The  suggestion  of  Dr.  Samuel  W.  Kelley  is  an  excellent 
one  {Ohio  State  Medical  Jour.,  November  i8,  1905)  of  having 
a  hard-rubber  pad  with  buttons  on  it,  folding  the  front  ends 
of  the  plaster  back  upon  itself  and  cutting  a  button-hole  in  the 
plaster  (figs.  201  and  202).  The  mother  can  remove  the  umbil- 
ical plate  evei"y  day  for  the  purpose  of  washing  the  skin  without 
disturbing  the  plaster,  and  she  can  easily  renew  any  part  of 
the  plaster  that  may  become  loosened.    In  Germany  the  method 


MECHANICAL  TREATMENT:  UMBILICAL.     357 

of  using  the  skin  and  subcutaneous  tissues  in  the  vicinity  of  the 
navel  as  a  compress  has  been  adopted  and  seems  to  have  met 
with  success.  The  skin  and  loose  tissue  on  either  side  of  the 
umbilicus  are  grasped  with  thumb  and  fingers  and  infolded,  the 
plaster  being  then  placed  over.  When  I  first  read  of  the 
method  it  impressed  me  as  being  particularly  good,  and  I  at 
once  adopted  it  in  my  clinic ;  but  we  found  that  there  was  great 
liability  to  ulceration  of  the  skin  surfaces  that  were  folded 
together,  and  soon  went  back  to  the  use  of  the  compress  and 
plaster,  as  already  described. 

Fig.  202. 


Dr.  S.  W.  Kelley's  method  of  combining  plaster  with  hard-rubber  plate.    Plaster  is  folded 
back  upon  itself,  and  has  button  holes  cut  in  it. 

The  length  of  time  required  to  cure  an  infant  of  umbilical 
hernia  seems  to  depend  somewhat  upon  its  age.  At  three 
months  of  age  it  can  ordinarily  be  cured  in  three  months,  but  at 
six  months  of  age  it  will  frequently  require  six  months,  while 
a  full  year  of  mechanical  support  is  usually  required  after  the 
child  walks.  When  it  is  a  year  old  I  seldom  resort  to  the 
plaster  and  compress,  experience  having  proven  that  a  light 
spring  controls  the  hernia  with  greater  certainty.  In  the  group 
of  umbilical  trusses  for  infants  will  be  seen  several  good  forms. 
My  preference  with  very  small  children  is  for  the  single-spring 
trusses  covered  Avith  either  hard  rubber  or  celluloid  so  that  they 
can  be  kept  perfectly  clean  and  worn  in  the  bath.     In  children 


358  ABDOMINAL  HERNIA. 

Group  of  Infant  Umbilical  Trusses. 


I.  Infant's  hard-rubbersingle-spring  umbilical        2.  Infant's  hard-rubber  single-spring  umbili- 
truss.     Sizes,  10  to  21  inches.  cal  truss.    (Youth's sizes,  22  to  29  inches.) 


3.  Youth's  double-spring  hard-rubber 
umbilical  truss. 


4.  Bow  spring  (leather  covered  )  cedar  pad 
umbilical  truss.  * 


5.   Fine  French  kid  or  cedar  pad. 
umbilical  truss. 


7.  Umbilical  belt  truss,  sateen  band,  elastic 
sides  to  lace  in  back.    Kid  or  hard- 
rubber  pad. 


6.  Double  band  elastic  hard-rubber  plate 
umbilical  truss. 


S.  Elastic  umbilical  truss,  hard-rubber 
cedar,   or  kid  pad. 


9.  Soft-rubber  belt  with  inflated  air  pad. 


MECHANICAL  TREATMENT:  UMBILICAL.     359 

of  three  years  and  over  I  am  quite  partial  to  light  double  springs 
with  the  fastening  in  the  back,  as  shown  in  fig.  203. 

The  selection  of  the  pad  or  button  that  presses  into  the 
umbilicus  is  a  matter  of  importance.  If  the  child  is  very  fat 
the  centre  projection  on  the  umbilical  pad  must  be  quite  prom- 
inent, in  order  to  reach  down  to  the  abdominal  wall;  if  very 
thin  such  a  prominent  centre  would  do  actual  harm  by  wedging 

Fig.  203. 


Umbilical  hernia  (in  a  child  3  years  old)  retained  fay  a  hard-rubber  truss,  the  spring  going 
around  the  body  on  both  sides. 


itself  into  the  umbilical  ring  and  preventing  closure.  Some- 
times in  very  thin  children  the  use  of  a  perfectly  flat  surface  is 
attended  by  better  results.  As  in  inguinal  hernia,  these  cases 
must  be  kept  under  the  frequent  observation  of  the  physician 
in  order  to  obtain  good  results.  The  children  are  growing 
rapidly,  and  this  growth  must  be  provided  for.  Here,  also, 
as  in  inguinal  hernia,  infants  are  good  truss  wearers  if  the  skin 
is  kept  perfectly  clean  and  dry. 


360  ABDOMINAL  HERNIA. 

Children  under  five  years  of  age  are  almost  always  cured  by 
tlie  means  suggested  if  they  are  kept  under  care;  the  curability 
of  umbilical  hernia  by  mechanical  support,  however,  diminishes 
rapidly  after  passing  the  third  year,  and,  while  in  recent  cases 
a  few  cures  may  be  obtained,  even  in  children  ten  or  twelve 
years  old,  this  fortunate  result  has  been  very  rare  in  my 
experience.  It  has  been  my  practice  to  recommend  operative 
cure  in  all  children  who  have  passed  the  tenth  year,  and  in  some 
much  earlier,  where  there  appeared  little  prospect  of  curing  by 
means  of  the  truss.  Where  springs  are  used  their  accurate 
adjustment  will  be  greatly  enhanced  by  resort  to  the  lead-tape 
diagram  method,  which  has  been  described  under  the  mechan- 
ical treatment  of  inguinal  hernia. 

Mechanical  Treatment  of  Umbilical  Hernia  in  the  Adult. 
— In  the  adult  umbilical  hernia  is  unquestionably  the  most 
difificult  of  all  herniae  to  treat  either  mechanically  or  surgically, 
and  for  this  reason  its  occurrence  should  always  be  looked 
upon  as  a  serious  matter  even  though  the  hernia  be  insignificant 
in  size  and  giving  no  immediate  discomfort.  In  fact,  the  most 
prompt  and  persistent  treatment  should  be  insisted  upon  from 
its  very  inception  in  order  to  protect  the  patient  against  the 
many  ills  and  dangers  that  are  sure  to  follow  its  neglect. 

While  there  is  not  such  a  large  variety  of  trusses  made 
for  this  form  of  hernia,  there  are  several  good  ones  from  which 
to  select  in  order  to  meet  the  special  indications  of  the  case. 
In  small  hernia  upon  a  person  of  medium  weight,  the  single 
spring  trusses  are  lighter,  more  convenient  and  consequently 
better.  Little  dependence  can  be  placed  upon  trusses  made  of 
elastic  1)ands.  and  caution  in  their  use  is  therefore  advised.  In 
those  cases  where  it  seems  advisable  to  use  a  truss  at  night  they 
answer  the  purpose  admirably,  but  under  their  use  during  the 
day  most  cases  grow  worse. 

In  selecting  springs  preference  should  always  be  given  to 
those  covered  by  hard  rubber  or  celluloid.  In  shaping  them  it 
must  be  borne  in  mind  that  those  covered  with  hard  rubber 
must  be  warmed  before  bendincf.     What  has  been  said  about 


MECHANICAL  TREATMENT:  UMBILICAL.     361 

Group  of  Adult  Umbilical  Trusses. 


I.    Celluloid  single-spring  umbilical  truss. 


2.     Double-spring  hard-rubber  umbilical  truss. 


3.     Chase  umbilical  truss.     Leather  cover,  cedar  pad. 


362  ABDOMINAL  HERNIA. 

Group  of  Adult  Umbilical  Trusses    ( Conimued). 


4.    Single-spring  hard-rubber  umbilical  truss. 


5.     Elliptic  double-spring  hard-rubber  umbilical  truss. 


6.     Bow-spring  hard-rubber  umbilical  truss. 


MECHANICAL  TREATMENT:  UMBILICAL.     363 

Group  of  Adult  Umbilical  Trusses    {Contiftued). 


7.    Elastic  umbilical  truss. 


8.     Narrow  band  elastic  umbilical  truss. 


9.     Bo\v-spring  leather  umbilical  truss'. 


10.    Elastic  umbilical  truss,  celluloid  plate. 


Concave  hard-rubber  pads. 


26i  ABDOMINAL  HERNIA. 

Group  of  Adult  Umbilical   Trusses     {Contitmcd). 


Concave  hard-rubber  pads  for  use  inside  of  abdominal  belts  in  irreducible  umbilical  hernia. 


II.     Combinatioa  belt  and  umbilical  pad. 


12.    Combination  belt  and  umbilical  pad  with  springs  outside  of  belt. 


MECHANICAL  TREATMENT:  UMBILICAL.     365 

Group  of  Adult  Umbilical  Trusses     {Cotttimied) , 


13.     Extra  hard-rubber  pad,  elliptic  spring,  and  band  to  be  used  in  combination  with 

abdominal  belt. 


^:ittate»«w.Mt«i^' 


14.     Hard-rubber  elliptic-spring  umbilical  truss  applied. 


15.    Belt  for  general  abdominal  support,  to  which  may  be  added  umbilical  pad  and  extra 
retaining  band.    Woven  silk  or  cotton-covered  thread. 


366 


ABDOMINAL  HERNIA. 


Oi'TLiNES  OF  Umbilical  Plates  and  Centres. 
Showing  Actual  Sizes. 


Fig.  204. 


Solid  cedar  pad,  5j<f  inches. 


Hard-rubber  (hollow)  navel  centres  for  the  umbilical  pad. 


MECHANICAL  TREATMENT:  UMBILICAL.     367 


selecting  a  centre-piece  for  the  plate  suitable  for  the  individual 
child  applies  with  even  greater  force  in  the  case  of  the  adult. 
Fat  people  must  have  a  deep  centre  and  thin  persons  one  that 

Outlines  of  Umbilical  Plates  and  Centres,  Showing 
Actual  Sizes     ( Con/inued). 


Hard-rubber  plates.  Size  3  is  4^x3^  inches  ;  size  2  is  6  :x.aH  inches,  and  size  i  is  7'%'X.S 
inches,  on  which  are  used  seven  sizes  of  detachable  centre  pads,  of  which  size  xx.  is  the  largest 
and  size  5  the  smallest. 


(See  fig.  204  for  an  illustration  of  the  size  of 
plates   and  centre-pieces   as   ordinarily  manufactured  by  the 


is  not  so  deep, 
plates  and  cei 
truss  makers.) 


368 


ABDOMINAL  HERNIA. 


For  fat  and  heavy  patients  the  double-spring  truss  will 
afford  a  firmer  and  more  secure  support.  In  these  trusses  the 
springs  fasten  on  stud-head  screws  that  are  solidly  fixed  in  the 
plate,  but  where  very  strong  pressure  is  desired  the  one  with 
an  elliptic  spring  is  better.      This  spring  is  attached  in  its 

Fig.  205. 


An  English  umbilical  truss,  adjusted.   {Eccles.) 

middle  and  the  ends  arch  out  away  from  the  plate.  When  the 
body  springs  are  fastened  upon  the  stud-head  screws  in  the  ends 
of  the  elliptic  spring  its  action  is  to  throw  the  plate  farther  in, 
giving  greatly  increased  pressure.  An  extremely  large  umbili- 
cal plate  rfig.  205).  with  a  prominent  centre,  is  used  in  Eng- 
land.    The  whole  truss  is  thicklv  covered  with  leather,  and 


MECHANICAL  TREATMENT:  UMBILICAL.     369 

compared  with  those  made  in  this  country  is  a  cumbersome 
affair. 

Where  the  whole  abdomen  is  pendulous,  it  is  frequently 
desirable  to  combine  general  abdominal  support  with  retention 
of   the   hernia,    as   shown   in   the    illustrations.      This   is    an 

Fig.  206. 


■< 


?.;>;  V  ■ 


/C"%. 


/o         "a 


Diagram  for  abdominal  belt  and  umbilical  truss  measure. —  i.  Umbilical  hernia : 
Circumference  on  line  with  navel  and  shape  by  lead  tape  (see  Truss-fitting,  Inguinal  hernia) 
on  same  line.  2.  Abdominal  belts:  Circumference  at  K,  L,  M;  length  from  6  to  8.  If'  an 
umbilical  plate  is  to  be  added,  give  distance  from  6  to  navel.  3.  Ventral  hernia  belts:  Cir- 
cumference M,  L,  K,  6  to  8.  Distance  of  top  of  pad  from  navel  to  9,  of  bottom  of  pad, 
10  to  II. 


admirable   combination   for   corpulent   people   suffering   from 
large  reducible  or  irreducible  umbilical  hernia.     The  belt  not 
only  gives  valuable  general  support,   but  prevents  the  truss 
24 


370 


ABDOMINAL  HERNIA. 


springs  becoming  imbedded  in  the  fat.  The  umbiHcal  plate, 
being  inside  the  beh,  is  also  held  more  securely  in  place. 
Where  a  belt  is  ordered  as  a  part  of  the  support,  careful  meas- 
ures of  the  abdomen  should  be  forwarded  to  the  manufacturer. 
The  diagram  shown  in  fig.  206  will  aid  the  physician  in  taking 
these  measures,  and  the  letters  w4iich  designate  the  points  of 
circumference  are  understood  by  all  reputable  manufacturers. 

Hernije  containing  large  omental  protrusions  are  very 
liable  to  inflammatory  conditions,  which  may  be  mistaken  for 
true  strangulation.   This  inflammation  is  ordinarily  due  to  pro- 


FiG.  207. 


English  rim-plate  concave-pad  truss  for  irreducible  umbilical  hernia.     {Eccles.) 

trusion  of  a  new  mass  of  omentum  and  its  constriction  at  the 
hernial  aperture.  If  allowed  to  follow  their  own  course, 
sloughing  is  liable  to  occur.  Long  continued  hot  applications 
I  feel  sure  favors  this  result.  I  have  found  the  use  of  ice  more 
satisfactory,  and  have  kept  it  on  for  several  days  at  a  time,  with 
the  most  happy  results.  Let  it  be  distinctly  understood  that  I 
do  not  approve  of  any  such  delay  if  there  is  the  least  indication 
of  intestinal  obstruction.  By  the  application  of  ice  and  daily 
gentle  manipulations,  the  hernia  can  frequently  be  restored 
to  its  former  condition. 

Irreducible  Umbilical  Hernia. — This  leads  to  the  mechan- 
ical treatment  of  those  cases  which  are  only  partially  reducible. 


MECHANICAL  TREATMENT:  UMBILICAL.     371 

A  few  of  these  can,  by  confinement  to  bed  and  repeated  gentle 
taxis,  be  converted  into  reducible  hernise.  At  least  an  attempt 
should  be  made  to  reduce  all  that  is  possible;  then  a  concave 
pad,  fitting  exactly  the  remaining  protrusion,  and  attached  to 
one  of  the  springs  already  described,  should  be  applied.  In 
large  people,  the  combination  of  belt  and  spring  with  concave 
pad  of  suitable  size,  is  especially  desirable.  After  wearing  one 
of  these  concave  pads  over  an  irreducible  hernia,  the  protrusion 
may  so  diminish  in  size  that  a  smaller  pad  will  be  required. 
The  English  use  a  form  of  truss  shown  in  fig.  207,  which,  it 
would  seem,  might  be  useful  in  the  cases  under  consideration. 
The  treatment  of  irreducible  umbilical  hernia  by 
mechanical  means  is  not  attended  by  an  amount  of  success  that 
is  encouraging.  In  fact  the  history  of  such  cases  is  one  of  con- 
stant increase  in  size,  discomfort,  and  danger.  Unless  there  is 
some  special  contra-indication  it  will  be  best  to  advise  such 
patients  to  submit  to  surgical  treatment. 


CHAPTER  XX. 
SURGICAL  CURE  OF  UMBILICAL  HERNIA. 

Those  having  little  practical  experience  will  find  the  litera- 
ture of  this  subject  confusing,  and  in  many  instances  mislead- 
ing, inasmuch  as  authors  differ  so  widely  in  their  statements. 
We  are  assured  by  some,  who  should  speak  with  authority, 
that  the  operations  for  the  cure  of  umbilical  hernia  are  par- 
ticularly dangerous  and  usually  followed  by  failure  to  obtain 
a  cure.  Then  again  men  of  such  ripe  experience  as  Dr.  George 
Ben  Johnson  of  Richmond  tells  us  (Medical  Register,  August 
15,  1897)  that  most  authors  are  too  conservative.  Dr.  John- 
son says,  "  I  am  astonished  at  the  cautious  manner  in  which 
some  of  our  best  authors  advise  the  procedure."  Those  of  us 
who  know  his  work  know  that  Dr.  Johnson  is  himself  a  con- 
servative man ;  we  also  know  that  some  of  these  umbilical  cases 
are  particularly  dangerous  cases  for  operative  treatment.  The 
truth  is  that  we  cannot  speak  positively  upon  the  subject  as  a 
whole;  we  must  attempt  to  separate  and  recognize  those  cases 
that  are  safe  for  operation,  and  when  we  are  forced  to  operate 
upon  those  that  are  dangerous  we  should  do  so  with  a  full 
understanding  of  the  responsibilities  involved. 

As  previously  stated,  most  umbilical  hernise  of  early  life 
need  never  come  to  the  operating  table,  if  given  proper 
mechanical  support  for  a  suitable  length  of  time.  In  some 
instances,  however,  the  muscular  defect  is  too  great  to  be  over- 
come and  the  question  will  arise  as  to  the  advisability  of 
operative  relief.  These  cases  may  all  be  classed  as  safe  for 
operation,  and  a  permanent  cure  is  quite  certain  to  follow.  I 
have  no  knowledge  of  a  fatality  or  a  failure  following  an 
operation  on  young  patients. 

Operations  upon  adults  of  middle  and  advanced  life  must 
be  considered  more  carefully,  and  examination  of  Dr.  Johnson's 

372 


SURGICAL  CURE:  UMBILICAL.  373 

"  excluded  "  list  will  at  once  show  the  reason  of  his  positive  and 
favorable  opinion.  Here  are  those  who,  according  to  his  opin- 
ion, should  not  be  operated  upon :  "  The  old  and  feeble,  where 
there  is  extensive  separation  of  the  recti  muscles  below  the 
umbilicus,  where  there  is  so  much  hypertrophied  omentum  that 
its  removal  would  prove  dangerous  to  life,  where  there  is 
extreme  atrophy  of  the  surrounding  muscles."  To  this  I 
would  add  the  excessively  fat,  who  are  liable  to  degeneration 
of  the  heart  as  well  as  other  muscular  structures.  We  at  once 
recognize  the  fact  that  a  large  percentage  of  umbilical  hernije 
as  seen  in  the  adult  come  within  the  limits  of  this  excluded 
list,  and  should  therefore  be  considered  as  extra-hazardous  as 
regards  danger  to  life  and  the  permanence  of  cure. 

My  personal  views  have  changed  materially  within  the 
past  ten  years.  Formerly  I  was  inclined  to  avoid  the  surgical 
treatment  of  umbilical  hernia  in  adults.  I  have,  however, 
had  the  mortification  of  seeing  some  of  those  same  cases, 
through  neglect  of  the  patient  or  my  own  inability  to  so  adjust 
support  as  to  control  the  hernia,  grow  gradually  but  surely 
worse.  When  first  seen  they  might  have  been  operated  upon 
with  a  small  amount  of  danger,  but  later  that  risk  has  increased 
many  times.  For  this  reason  I  have  come  to  feel  that  all  cases 
of  umbilical  hernia  should,  if  possible,  be  operated  upon  while 
the  protrusion  is  small.  The  larger  these  herni?e  become  the 
greater  are  the  dangers  attending  their  cure,  and  the  poorer 
are  the  structures  which  are  used  in  effecting  closure  of  the 
hernial  ring. 

Operation. — The  preparation  of  the  patient  should  be 
made  with  all  the  extreme  care  that  would  be  exercised  in  any 
other  laparotomy.  Even  greater  attention  must  be  given  to 
the  sterilization  of  the  skin,  which  is  frequently  in  bad  condi- 
tion either  from  ulceration  due  to  over-distention,  or  from  the 
effects  of  truss-wearing. 

Many  authors  direct  that  a  vertical  incision  shall  be  made 
over  the  most  prominent  part  of  the  tumor.  This,  I  am  con- 
vinced, is  fraught  with  great  danger.      The  incision  should 


374  ABDOMINAL  HERNIA. 

rarel}^  if  ever,  be  made  in  the  median  line,  as  at  this  point  the 
skin  and  sac  are  usually  so  intimately  united  as  to  make  their 
separate  division  impossible ;  furthermore,  the  intestine  may 
be  adherent  to  the  interior  of  the  sac  and  opened  at  the 
first  sweep  of  the  knife.  The  incision  should  be  elliptical 
in  form,  beginning  well  above  and  spreading  out  on  each  side 
of  the  na\-el  so  as  to  avoid  to  a  great  extent  the  risk  of  opening 
into  the  sac.  The  dissection  of  the  subcutaneous  fat  can  be 
rapidly  carried  down  to  the  aponeurosis  and  then  carefully 
.  upon  this  surface  towards  the  neck  of  the  sac.  When  the  neck 
of  sac  thus  approached  is  freed  on  all  sides  it  can  be  lifted  up 
and  an  opening  made  through  it  to  examine  its  contents,  all 
reducible  parts  having  been  previously  returned  to  the  abdomen. 
If  the  sac  is  free  it  can  at  once  be  cut  away  at  its  neck,  leaving 
the  adherent  fundus  attached  to  the  removed  ellipse  of  skin. 
If  on  opening  the  side  of  the  sac  a  mass  of  adherent  omentum  is 
found,  it  is  best  to  draw  it  out  through  this  opening,  ligate  it  by 
multiple  ligatures,  cut  it  away  and  reduce  the  stump.  Then 
cut  away  the  sac,  which  will  be  removed  with  attached  omen- 
tum, skin,  and  umbilicus.  This  method  saves  much  valuable 
time  that  is  lost  when  opening  directly  into  the  top  of  the  sac; 
If  it  is  found  that  intestine  is  adherent  then  it  is  better  to  care- 
fully extend  the  side  incision  into  the  sac,  laying  it  wide  open. 
Patches  of  sac  firmly  adherent  to  the  bowel  should  be  cut  out 
and  left  upon  the  intestinal  surface  rather  than  incur  risk  of 
serious  laceration  by  attempting  to  strip  them  loose.  In  cutting 
away  the  sac  it  should  be  far  enough  from  the  abdominal  sur- 
face to  leave  plenty  of  material  for  closure  of  the  peritoneum. 

The  method  of  closing  the  umbilical  ring  should  depend 
largely  upon  the  conditions  found.  If  the  surrounding  struc- 
tures are  of  normal  thickness,  the  stripping  away  of  the  peri- 
toneum from  the  edges  of  the  ring,  its  closure  by  plain  catgut, 
and  then  the  splitting  of  the  aponeurotic  structures  into  two 
layers  and  their  separate  closure,  preferably  by  kangaroo  ten- 
don, and  finally  the  closure  of  the  skin,  will  result  in  an  effective 
repair  of  the  distended  ring. 


SURGICAL  CURE:  UMBILICAL.  375 

If  the  case  is  one  where  intra-abdominal  pressure  will  be 
great  and  liable  to  tear  the  sutures  through  the  tissues,  put  in 
before  closing  the  tendinous  layers,  three  or  four  relaxation 
sutures  of  silkworm  gut.  These  are  put  in  by  a  long  needle 
between  the  layers,  if  the  wall  has  been  split,  or  just  outside  of 
the  peritoneum  if  not,  and  extended  well  back  from  the  wound 
on  either  side.  They  are  not  tied  until  the  other  steps  in  the 
operation  are  complete. 

The  wound  is  now  closed  in  the  following  manner :  Peri- 
toneum by  continuous  suture  of  catgut.  Each  layer  of 
abdominal  wall  separately,  by  heavy  strands  of  chromicized 
kangaroo  tendon,  and  skin  by  subcutaneous  catgut.  The 
relaxation  sutures  are  then  drawn  tight  and  tied.  These  are 
cut  and  removed  about  the  tenth  or  twelfth  day.  The  usual 
dressings  under  a  firm  binder  are  applied.  This  is  not  dis- 
turbed for  ten  days,  unless  there  is  pain  or  elevation  of 
temperature. 

Overlapping  of  Abdominal  Wall. — At  the  meeting  of  the 
Medical  Society  of  the  State  of  New  York  at  Albany,  February 
I,  1899,  in  a  paper  on  the  treatment  of  umbilical  hernia,  I  made 
the  following  statement  ( Transactions  Med.  Soc,  State  of  New 
York,  1899)  :  "  In  several  cases  where  the  abdominal  wall 
was  thin,  and  intra-abdominal  pressure  not  great,  I  have  suc- 
ceeded in  overlapping  the  cut  edges,  so 'that,  when  complete,  it 
gave  two  layers  of  tendinous  structure  in  the  median  line. 
I  am  quite  partial  to  this  method,  but  in  some  cases  it  cannot 
be  used  on  account  of  the  extent  to  which  the  abdominal  cavity 
is  thereby  diminished." 

I  had  previous  to  1899  operated  upon  6  cases  by  this 
method,  my  first  having  been  on  March  9,  1896,  at  the  New- 
York  Post-Graduate  Hospital.  This  statement  is  made 
definitely  because  of  the  fact  that  American  writers  have 
recently  been  accused  (P.  T.  Diaknow,  M.D.,  Annals  of  Sur- 
gery, July,  1906)  of  not  giving  credit  to  Russian  authors 
whose  first  writings  were  according  to  Dr.  Diaknow,  by  him- 
self in  1898,  and  Dr.  Sapiejhko  {Annals  of  Russian  Surgery) 


376 


ABDOMINAL  HERNIA. 


in  1900.  The  truth  is  that  eveiy  operator  of  good  surgical 
common  sense  would  be  very  likely  sooner  or  later  to  see  his 
opportunity  of  making  a  closure  of  this  type,  and  without  feel- 
ing that  he  had  made  an}-  great  discovery.  Dr.  Joseph  A. 
Blake  of  New  York  was  perhaps  the  first  to  demonstrate  the 
method  properly  by  drawings  showing  its  technique  (Medical 

Fig.   208. 


Vertical  overlapping  of  abdominal  wall  in  umbilical  and  veiitxal  hernia.      (Size  of 
incision  exaggerated.) 

Record,  May  25,  1901).  His  claims  for  it  were  as  follows: 
"(i)  The  doubling  of  the  abdominal  wall  at  the  hernial  site. 
(2)  The  breaking  of  the  lines  of  suture.  (3)  The  broad  sur- 
faces for  union.  (4)  The  obliteration  of  the  separation  of  the 
recti,  and  the  reduction  in  the  size  of  the  abdomen." 

After  several  years'  experience  with  this  operation  I  feel 
that  the  claims  made  for  it  are  fully  justified.     The  method  is 


SURGICAL  CURE:  UMBILICAL.  377 

executed  as  follows :  After  the  removal  of  the  sac,  the  linea 
alba,  with  the  peritoneum,  is  divided  for  one  and  a  half  or  two 
inches  above  and  below  the  umbilical  ring.  The  peritoneum  is 
separated  from  the  abdominal  wall  on  both  sides  to  whatever 
distance  the  overlapping  can  be  done,  and  it  is  then  closed  in 
the  median  line  by  a  running  suture  of  catgut.  The  denuded 
aponeurosis  of  the  right  side  is  slipped  under  that  of  the 
left  and  fastened  there  by  interrupted  sutures.  Kangaroo 
tendon  is  preferred  for  this  purpose.  The  other  edge  of  the 
flap  is  now  united  to  the  right  side  by  a  running  suture  of  the 
same  material  (fig.  208).  Blake  used  the  interrupted  suture 
for  the  closure  of  both  lines.  The  skin  is  closed  in  the  usual 
way.  This  gives  a  broad  surface  of  union  and  has  proven 
protective  in  cases  that  seemed  almost  hopeless  so  far  as 
permanence  of  cure  was  concerned.  In  some  instances  the 
intra-abdominal  pressure  is  so  great  as  to  make  it  almost  impos- 
sible to  get  the  material  w^ith  which  to  do  this  overlapping. 
These  cases  should,  if  possible,  be  recognized  before  they  come 
to  the  table  and  the  pressure  relieved  by  light  diet  for  some 
days  before  the  operation,  and  the  complete  freeing  of  the 
intestinal  tract  by ,  cathartics. 

Dr.  William  J.  Mayo  of  Rochester,  Minn.,  prefers  to  do 
the  overlapping  in  a  transverse  direction  and  his  operation  has 
been  largely  followed  in  the  West.  My  own  experience  with 
it  would  not  lead  me  to  adopt  it  as  a  routine  method.  He 
gives  the  steps  of  his  operation  of  transverse  overlapping  of 
the  abdominal  wall  as  follows  {Jour.  A.M. A.,  July  25,  1903)  : 
"(i)  Transverse  elliptical  incisions  are  made  surrounding  the 
umbilicus  and  hernia ;  this  is  deepened  to  the  base  of  the 
hernial  protrusion. 

(2)  The  surfaces  of  the  aponeurotic  structures  are  care- 
fully cleared  two  and  a  half  to  three  inches  in  all  directions 
from  the  neck  of  the  sac  (fig.  209). 

(3)  The  fibrous  and  peritoneal  coverings  of  the  hernia  are 
divided  in  a  circular  manner  at  the  neck,  exposing  its  contents. 
If  intestinal  viscera  are  present,  the  adhesions  are  separated 


378  ABDOMINAL  HERNIA. 

and  restitution  made.  The  contained  omentum  is  ligated  and 
removed  with  the  entire  sac  of  the  hernia,  and  without  tedious 
dissection  of  the  adherent  omentum. 

(4)   An  incision  is  made  through  the  aponeurotic  and 
peritoneal  structures  of  the  ring,  extending  one  inch  or  less 

Fig  .  209. 


Transverse  elliptic  incision  to  aponeurosis,  and  circular  division  of  sac  neck.    (Afayo.) 

transversely  to  each  side,  and  the  peritoneum  is  separated  from 
the  under  surface  of  the  upper  of  the  two  flaps  thus  formed. 

(5)  Beginning  from  two  to  two  and  one-half  inches  from 
the  margin  of  the  upper  flap,  three  to  four  mattress  sutures  of 
silk  or  other  permanent  material  are  introduced,  the  loop  firmly- 
grasping  the  upper  margin  of  the  lower  flap ;  sufficient  traction 
is  made  on  these  sutures  to  enable  peritoneal  approximation 


SURGICAL  CURE:  UMBILICAL. 


379 


with  running  suture  of  catgut.  The  mattress  sutures  are  then 
drawn  into  position,  shding  the  entire  lower  flap  into  the  pocket 
previously  formed  between  the  aponeurosis  and  the  peritoneum 
above  (fig.  210). 


Fig.  210. 


Lower  flap  slipped  into  pocket  between  peritoneum  and  aponeurosis.    Mattress  sutures 
ready  to  tie.     (Mayo.) 

(6)  The  free  margin  of  the  upper  flap  is  fixed  by  catgut 
sutures  to  the  surface  of  the  aponeurosis  below,  and  the  super- 
ficial incision  closed  in  the  usual  manner.  In  the  larger 
hernise  the  incisions  through  the  fibrous  coverings  of  the  sac 
may  be  made  somewhat  above  the  base,  thereby  increasing 
the  amount  of  tissue  available  for  use  In  the  overlapping 
process  "  (fig.  211). 


380  ABDOMINAL  HERNIA. 

As  to  whether  the  overlapping  shall  be  in  a  vertical  or 
transverse  line  must,  it  seems  to  me,  be  decided  by  the  oper- 
ator after  the  parts  are  open  and  it  can  be  seen  in  which 
direction  there  is  the  least  resistance.  In  making  this  a  basis 
upon  which  the  incision  rests  it  has  appeared  to  me  that  in  the 

Fig.  211. 


I'pper  flap  closed  over  lower  and  stitched  to  aponeurosis.     (Mayo.) 

greater  number  of  cases  it  would  be  easier  to  overlap  the 
aponeurotic  structures  vertically  than  transversely.  Further- 
more, this,  to  my  mind,  more  nearly  restores  the  normal  relative 
position  of  the  recti  muscles,  which  are  so  widely  separated  in 
the  large  hernire  in  which  one  or  the  other  of  these  operations 
seems  so  well  calculated  to  cure. 

The  excision  of  the  umbilicus,  which  I  have  for  years  fol- 


SURGICAL  CURE:  UMBILICAL.  381 

lowed  in  nearly  every  case,  is  also  believed  to  be  an  important 
step  toward  a  permanent  cure.  The  umbilical  ring  is  a  weak 
spot  in  the  abdominal  wall  because  of  its  surrounding  a  mass 
of  tissue  that  is  never  completely  obliterated.  When  operating, 
by  removing  entirely  this  mass,  we  materially  aid  in  the  abso- 
lute closure  of  that  ring.  The  suggestion  that  the  sheath  of 
the  recti  be  cut  and  their  fibres  united  in  the  median  line  is  not 
in  many  cases  practicable,  especially  in  large  hernise  where 
there  is  special  difficulty  in  obtaining  a  cure,  because  these 
muscles  are  so  widely  separated  and  so  thin  that  it  is  not 
possible  to  bring  them  together. 

The  after  treatment  of  cases  operated  upon  for  umbilical 
hernia  should  differ  somewhat  from  that  given  in  the  inguinal 
and  femoral  types.  The  patient  should  be  confined  to  bed  for 
at  least  two  weeks  and  in  very  large  hernise  even  longer.  A 
good  snug  binder  with  a  compress  over  the  former  site  of  the 
hernia  should  be  worn  for  from  two  to  three  months.  If  the 
hernia  has  been  large  and  the  structures  poor  it  is  far  better 
to  have  a  good  woven  elastic  belt  worn  for  a  year  or  even 
permanently  than  to  take  the  risk  of  losing  the  benefits  of  the 
operation.  It  is  believed  the  best  policy  to  tell  patients  who 
have  been  operated  upon  for  this  form  of  hernia  that  the  risk  of 
recurrence  is  much  greater  than  in  other  forms,  and  that  much 
depends  upon  them  and  the  care  they  take  of  themselves. 

CONGENITAL   UMBILICAL    HERNIA. 

It  scarcely  comes  within  the  intent  of  this  work  to  speak  of 
congenital  umbilical  hernia,  which  in  reality  is  not  hernia,  but 
rather  a  malformation  or  lack  of  development.  It  is  not  a  pro- 
trusion of  abdominal  contents  through  the  umbilical  ring,  but  a 
portion  of  the  viscera  which  has  never  been  closed  within  the 
abdominal  cavity.  The  umbilical  ring  has  really  never  formed, 
and,  as  in  spina  bifida,  the  lateral  halves  of  the  body  wall  have 
failed  to  unite.  The  subject  is  briefly  discussed  here,  however, 
to  correct  a  rather  common  error  among  physicians  that  most 
umbilical  hernise  in  infancy  are  of  the  congenital  type. 


382  ABDOMINAL  HERNIA. 

This  condition  is  found  at  the  birth  of  the  child,  the 
abdominal  wall  having  failed  completely  to  enclose  its  normal 
contents.  There  is  an  unclosed  cleft  in  the  wall  and  the  pro- 
truding viscera  are  covered  only  by  the  attenuated  coverings  of 
the  umbilical  cord.  Lindfors  (Centralblatt  filr  Gyndk,  p.  255, 
1884)  gives  the  number  of  cases  of  this  malformation  in  21,000 
confinements,  at  the  Munich  Lying-in  Hospital,  as  i  in  every 
5,184  births.  In  size  it  may  be  anywhere  from  that  of  a  walnut 
to  complete  eventration  containing  in  addition  to  the  intestinal 
tract  the  stomach,  liver,  spleen,  and  even  the  heart. ^ 

Diagnosis. — The  sac  is  translucent,  and  its  contents  are 
usually  intestine,  but  may  be  a  part  or  the  whole  of  any  of  the 
abdominal  viscera.  Diagnosis  should  not  be  difficult,  but  doubt 
may  be  caused  by  possible  confusion  with  hydrocele  of  the 
umbilical  cord.  The  treatment  of  these  cases  is  far  from  satis- 
factory, but  all  authors  agree  that  in  immediate  operation  there 
is  greater  safety. 

Dr.  Willis  Macdonald  {Am.  Jour.  Ahst.,  p.  7,  1890)  gives 
a  history  of  12  cases  treated  by  compress  and  bandage,  of  which 
9  died,  while  of  19  others  subjected  to  early  laparotomy  only  2 
died.  The  tumor  may  be  partially  or  fully  reduced,  and 
retained  by  dry  aseptic  gauze  dressings  held  in  place  by  strips 
of  zinc  oxide  plaster.  The  tumor  must  be  handled  with  extreme 
caution  and  this  dressing  merely  employed  while  preparing  for 
an  operation. 

The  operation  consists  in  closure  of  abdominal  wall  over 
the  stump  of  the  sac,  after  that  has  been  tied  off  and  cut  away, 
A  belly-band  with  compress  should  be  worn  for  several  months 
afterwards. 

^  Those  who  wish  to  follow  the  subject  more  fully  are  advised  to 
consult  the  very  valuable  article  upon  the  subject  by  Dr.  Charles  Green 
Cumston,  of  Boston   {Medical  Record,  September  23,  1905). 


CHAPTER  XXI. 
VENTRAL  HERNIA. 

A  protrusion  of  the  abdominal  contents  at  any  part  of  the 
abdominal  wall  other  than  the  umbilical,  inguinal,  or  femoral 
region  may  be  correctly  termed  a  ventral  hernia.  In  order  to 
constitute  a  hernia  the  tumor  must  have  a  neck  and  a  lining  of 
peritoneum.  Those  cases  of  deficiency  at  birth  of  the  muscular 
wall,  with  consequent  bulging  of  one  side  or  a  part  of  one  side 
of  the  abdomen,  are  looked  upon  as  congenital  malformations 
rather  than  ventral  hernise. 

The  two  principal  causes  of  ventral  hernia  are  defective 
points  in  the  tendinous  closure  of  the  abdominal  wall,  and 
traumatism.  The  latter  in  itself  forms  an  important  division 
of  the  subject.  Eccles  {Hernia,  p.  190)  uses  the  terms  "  spon- 
taneous "  and  "  traumatic  "  ventral  hernia.  As  these  terms 
are  concise  and  expressive  they  will  be  used  in  discussion. 

Spontaneous  Ventral  Hernia. — Macready,  in  collecting 
statistics  on  this  subject,  found  that  this  form  was  nearly  four 
times  more  frequent  in  the  male  than  in  the  female,  and  that  it 
occurred  most  frequently  in  middle  life,  although  it  may  be 
found  at  any  age.  In  21,812  hernicC  examined,  38  ventral 
hernise,  or  i  in  every  574  cases,  were  found. 

Its  relation  to  other  herniee  is  shown  by  the  following 
table  from  his  work: 


Sex. 

Inguinal. 

Femoral. 

Umbilical. 

Vent  in  Linea 
Alba. 

Ventral 
+  Inguinal. 

Male 

17,538 
1,803 

461 
1,197 

209 
566 

15 
6 

15 

2 

Female 

Spontaneous  ventral  hernia  never  protrudes  through 
muscular  tissue,  but  always  through  some  of  the  tendinous 
structure  of  the  abdominal  wall.  It  is  therefore  most  fre- 
quently   found    in    the    median    line    coming   through    some 

383 


384  ABDOMINAL  HERNIA. 

defective  spot  in  the  linea  alba,  but  it  may  come  through  at 
eitlier  edge  of  the  recti  muscles,  the  linea  transversa,  or  linea 
semilunaris.  Various  names  have  been  applied  to  it  according 
to  the  location  of  the  hernia  (as,  epigastric  ventral  hernia  to  all 
of  those  protruding  above  the  navel),  but  here,  as  in  other 
parts  of  this  work,  multiplicity  of  names  will  be  avoided  as 
leading  only  to  confusion. 

The  linea  alba  being  weaker  in  structure  above  than  below 
the  navel,  we  find,  as  might  be  expected,  a  greater  number  of 
ventral  protrusions  above  this  point.  Protrusions  of  subperi- 
toneal fat  (commonly  called  lipoma)  through  these  openings 
may  simulate  ventral  hernia  so  closely  as  to  defy  diagnosis 
before  operation.  This,  however,  is  unimportant,  as  they  are 
not  only  frequently  the  forerunners  of  true  hernia,  but  by 
traction  upon  the  peritoneum  they  are  equally  painful.  Some 
authors  have  called  these  tumors  fatty  hernise,  but  it  is  hardly 
necessary  to  give  them  any  title  other  than  ventral  hernia,  diag- 
nosis seldom  being  made  before  operation.  These  remarks  do 
not  apply  to  true  lipomata  that  form  in  the  cellular  tissue  out- 
side of  the  abdominal  wall  and  which  can  usually  be  readily 
lifted  up  from  the  muscular  surface.  In  the  latter  cases  there 
is  ordinarily  no  pain  or  discomfort  and  the  patient  is  concerned 
in  the  growth  merely  as  something  abnormal. 

Spontaneous  ventral  hernia  is  usually  found  as  a  small 
round  tumor  varying  in  size  from  the  end  of  the  little  finger 
to  that  of  an  English  walnut.  Cases  have,  rarely,  been 
recorded  where  the  tumor  has  become  large  and  pendulous, 
but  such  have  not  come  within  my  own  experience.  The  con- 
tents of  these  hernise  are  most  frequently  omentum,  but  may 
be  intestine  or  both.  The  sac  is  frequently  small  and  at  the 
base  of  the  subperitoneal  fat  which  has  protruded  first,  drag- 
ging the  peritoneum  through  the  aperture  after  it.  These 
small  tumors  may,  in  many  instances,  be  demonstrated  by 
having  the  patient  lie  prone  on  a  hard  surface  and  then  attempt 
to  raise  his  head  and  slioulders.  In  other  cases  they  are  better 
found  by  having  the  patient  stoop  forward  and  cough  while 
standing. 


VENTRAL  HERNIA.  385 

Symptoms. — The  amount  of  pain  and  discomfort  that 
frequently  attend  this  form  of  hernia  is  entirely  out  of  propor- 
tion to  the  size  of  the  swelling.  The  diagnosis  of  obscure 
abdominal  trouble  would  many  times  be  made  clear  by  the 
discovery  of  this  apparently  insignificant  "  lump."  The  patient 
may  know  that  it  is  there  and  still  not  associate  his  abdominal 
trouble  with  it.  I  have  seen  several  cases  where  the  overlook- 
ing of  a  small  ventral  hernia  has  led  to  the  patient's  great  dis- 
comfort and  unnecessary  expense.  One  man  upon  whom  I 
operated  had  been  treated  by  various  physicians  for  "  dys- 
pepsia," "  renal  colic,"  "  gall-stones,"  "  ulcer  of  the  stomach," 
and  was  finally  told  that  his  distress  was  due  to  some  malignant 
growth.  He  had  called  the  attention  of  one  or  two  to  this 
little  swelling  about  two  and  a  half  inches  above  the  navel  and 
a  little  to  the  left  of  the  median  line,  but  was  told  that  it  was 
of  no  account.  In  this  case,  as  in  some  others  I  have  seen, 
there  was  no  local  pain.  These  little  protrusions  may  cause 
dragging  abdominal  pains  and  gastro-intestinal  disturbances 
quite  remote  from  the  seat  of  the  trouble.  "  Cramps  "  and 
vomiting  were  both  present  in  the  case  above  referred  to,  and 
yet  at  operation  nothing  was  found  in  the  sac  but  a  very  small 
piece  of  adherent  omentum.  The  cure  was  absolute  both  as 
to  the  distressing  symptoms  and  the  hernial  protrusion.  Not- 
withstanding these  symptoms  actual  strangulation  seldom 
occurs  in  this  form  of  hernia.  Lockwood  {"  Hunterian  Lec- 
tures on  the  Morbid  Anatomy,  Pathology,  and  Treatment  of 
Hernia,"  p.  137)  found  one  of  the  appendices  epiploicse  of  the 
colon  protruding  through  a  small  hole  in  the  linea  semilunaris 
at  the  level  of  the  anterior  superior  spine  of  the  ilium  and 
incarcerated.  It  can  be  readily  seen  what  an  amount  of  disturb- 
ance would  result  from  such  a  condition  without  producing 
symptoms  of  intestinal  obstruction. 

Treatment. — The  treatment  of  spontaneous  ventral  hernia 
by  mechanical  means  is  not  usually  attended  by  any  great 
degree  of  success.  They  are  seldom  fully  reducible  on  account 
of  the  pro-truding  fat  outside  of  the  sac,  and  they  are  at  points 

25 


386       -  ABDOMINAL  HERNIA. 

on  the  body  where  the  accurate  adjustment  of  a  truss  is 
extremely  difficult.  I  have  usually  had  greater  success  with  a 
light  double-spring  umbilical  truss  than  any  other.  The  pad 
may  be  much  smaller  than  that  used  in  umbilical  hernia  and  its 
inner  surface  nearly  flat.  The  plates  ordinarily  used  on  the 
youth's  umbilical  trusses  answer  this  purpose  very  well.  If  the 
protrusion  is  near  or  below  the  navel  the  plate  may  be  held  in 
place  by  an  elastic  belt. 

Operative  Treatment, — If  there  is  considerable  pain 
— and  these  cases  seldom  seek  relief  unless  there  is — it  is 
believed  that  they  should  at  once  submit  to  the  operative 
cure  of  the  condition.  They  are  unquestionably  the  most  satis- 
factory of  all  hernise  under  surgical  treatment.  The  opera- 
tion consists  in  an  incision  just  large  enough  to  enucleate  the 
tumor  which  is  almost  always  present,  freeing  its  neck  so  that 
fresh  peritoneum  is  drawn  into  the  hernial  opening,  then  open- 
ing the  sac  and  liberating  whatever  is  found.  The  neck  of  the 
sac  is  ligated  with  plain  catgut,  and  if  it  has  previously  been 
freed  from  the  edges  of  the  aperture  its  stump  will  drop  back 
into  the  abdominal  cavity,  and  the  opening,  which  is  usually 
very  small,  can  be  readily  closed  by  kangaroo  tendon  or 
chromic  gut. 

Oskar  Witzel  {Saminl.  Klin.  Vortr.  Volkmann,  1890,  No. 
10,  p.  45),  noticing  that  these  openings  in  the  linea  alba  were 
usually  wider  from  side  to  side,  advised  their  closure  in  a 
transverse  line.  The  direction  of  closure  should  be  in  the  line 
of  least  resistance  and  the  edges  should  be  overlapped  if  pos- 
sible. "  The  abdomen  should  be  entered  in  every  case  in  order 
to  free  adhesions  that  may  exist."  Personally  I  have  not  found 
that  necessary,  but  certainly  would  not  hesitate  to  do  so  if  in 
the  least  doubt  aJ^out  having  fully  liberated  any  adhesions 
present. 

Traumatic  Ventral  Hernia. — When  we  speak  of  traumatic 
ventral  hernia  we  have  reference  to  hernia  following  some  form 
of  injury  to  the  abdominal  wall.  The  injury  may  have  been  in 
the  form  of  an  abscess  or  a  blow,  but  it  comes  far  more  fre- 


VENTRAL  HERNIA. 


387 


quently   from   some   incisive   wound   which   has    divided   the 
muscular  fibre. 

In  the  author's  early  experience,  shortly  after  the  Civil 
War,  several  cases  of  this  type  were  seen  which  resulted  from 
stab  wounds  usually  inflicted  by  the  bayonet.  These  cases 
were,  so  far  as  seen,  all  small  protrusions  which  were  easily 
controlled  by  simple  mechanical  supports.     The  experience  of 

Fig.  212. 


Post-operative  ventral  hernia,  after  six  operations  for  cure.    Woman  34  years  old.    Original 
operation  was  ovariotomy. 


recent  years,  however,  has  been  with  ventral  hernice  of  quite  a 
different  type,  enormous  in  size  and  extremely  difficult  to  con- 
trol. They  have  followed  the  line  of  the  surgeon's  knife  in 
incisions  of  the  abdominal  wall.  A  very  common  form  of  this 
hernia  is  shown  in  fig.  212.  The  woman  there  shown  was  at  the 
time  of  this  photograph  only  thirty-four  years  old.  Her  orig- 
inal operation  was  for  an  ovariotomy,  the  reason  for  which 
could  never  be  ascertained.  Following  apparent  recovery  an 
abdominal  abscess  formed  and  required  evacuation.     On  recov- 


388 


ABDOMINAL  HERNIA. 


er^'  from  this  the  woman  became  enormously  fat  and  the  hernia, 
which  had  been  present  from  the  first,  increased  to  a  size  equal 
to  that  of  her  head.  Four  successive  attempts  to  cure  the 
hernia  failed  owing  to  lack  of  material  with  which  to  close  the 
enormous  opening  present. 

Unfortunately  hernia  due  to  stretching  of  an  abdominal 
cicatrix  is  quite  common,  its  frequency,  as  a  rule,  depending  on 

Fig.  213. 


Irregular  deposit  of  fat  over  right  inguinal  region,  but  no  hernia.    Case  operated  upon  five 
years  previously  for  ventral  hernia,  size  of  large  cocoa-nut. 

the  manner  in  which  the  wound  of  a  laparotomy  is  closed  and 
want  of  care  in  providing  the  patient  with  a  proper  and  well- 
fitting  abdominal  bandage  either  for  a  time  or  constantly,  as 
the  case  may  demand.  Even  in  these  days  of  asepsis,  from  lack 
of  care  at  times,  suppuration  does  take  place  with  the  resulting 
granulation  instead  of  primary  union.  Diagnosis  usually  is 
easily  made,  but  in  some  instances  deposit  of  fat  may  be  mis- 
leading as  shown  in  fig.  213. 


VENTRAL  HERNIA. 


389 


A  very  common  type  of  traumatic  ventral  hernia  are  those 
following  operations  for  appendicitis.  Traumatic  ventral 
hernije  following  all  abdominal  operations  are  fortunately 
much  less  frequent  than  they  were  ten  years  ago  from  the  fact 
that  surgeons  fully  appreciate  its  serious  liability  and  are  using 
every  possible  precaution  to  prevent  its  occurrence. 

Fig.  214, 


Post-operative  ventral  hernia.     Perforating  g:un-shot  wound.     Entrance  of  ball  gluteal,  exit 
inguinal  region.     Hernia  the  result  of  operative  attempts  to  close  suppurating  sinus. 

A  few  years  ago  the  operation  for  the  removal  of  the 
appendix,  even  where  no  abscess  existed,  involved  the  cutting 
directly  across,  with  consequent  destruction  of,  the  internal 
oblique  muscle,  and  all  the  nerves  and  blood  vessels  with  which 
this  region  is  so  richly  endowed.  Complete  restoration  of  the 
parts  was  practically  impossible  and  hernia  resulted  in  a  large 
proportion  of  cases.     This  in  some  abscess  cases  may,  even 


390 


ABDOMINAL  HERNIA. 


now,  be  a  necessity  as  a  life-saving  measure,  but  most  surgeons, 
in  this  country  at  least,  have  learned  that  quite  extensive  work 
can  be  done  in  this  region  by  splitting  each  muscle  in  the  direc- 
tion of  its  fibres  and  holding  them  apart  by  retractors.  Where 
the  abdomen  is  entered  by  this  method  and  deep  drainage  is  not 
required  ventral  hernia  very  seldom  results.     The  case  shown 

Fig.  215. 


Front  view  of  previous  case. 

in  fig.  214  and  215  is  of  rather  unusual  form,  and  resulted  from 
the  indiscriminate  cutting  away  of  the  muscles  of  the  lower 
abdomen  in  an  attempt  to  cure  a  sinus  following  a  gunshot 
wound.  The  sinus  was  of  very  little  importance  when  it  is 
considered  in  connection  with  the  hernia  that  was  the  direct 
result  of  the  operative  work,  which  also  failed  in  its  original 
purpose.  ' 


VENTRAL  HERNIA. 


391 


Traumatic  ventral  hernise  are  as  varied  in  size  and  shape 
as  the  patients  are  numerous.  When  the  protrusion  once  starts 
it  increases  rapidly  unless  checked  by  suitable  and  prompt  treat- 
ment. In  its  passage  through  the  wall  there  are  usually  some 
fibrous  bands  which  retard  a  portion  of  the  tumor  and  cause 
it  to  become  irregular  in  shape ;  it  may  come  out  on  both  sides 

Fig.   2 1 6. 


Bilateral  post-operative  ventral  hernia,  in  woman  aged  44  years.    Hysterectomy  and  ovario- 
tomy seven  years  previously. 


of  the  median  line,  as  shown  in  fig.  216,  or  it  may  protrude 
at  several  different  places  along  the  line  of  incision.  The 
contents  of  the  hernise  under  consideration  may  be  any  of 
the  abdominal  or  pelvic  viscera,  as  in  other  forms  of  hernia. 
(Dr.  Howard  Kelly  (Gynecology,  vol.  ii,  p.  466)  shows  a 
photograph  of  a  woman  upon  whom  previous  celiotomy  had 
been  done,  with  pregnant  uterus  protruding  ^  through  a 
traumatic  ventral  hernia.     She  had  a  normal  labor  at  term  and 


392  ABDOMINAL  HERNIA 

was  delivered  of  a  living  child.)  Omentum  is  usually  the  first 
to  protrude  and  as  the  opening  enlarges  intestine  soon  follows. 
Adhesions  quickly  form  between  the  omentum  and  sides  of  the 
sac  and  not  uncommonly  between  one  of  these  and  the  intestine. 
In  its  earliest  stage  it  is  freely  reducible,  but  if  allowed  to  go 
untreated  it  very  shortly  becomes  only  partially  so.  It  is 
usually  not  very  painful  at  first,  but  as  it  increases  in  size  is 
not  only  more  painful  but  is  accompanied  by  a  sense  of  weak- 
ness that  borders  closely  upon  prostration.  Strangulation  of 
these  large  traumatic  ventral  herni?e  is  rarely  reported,  as  the 
neck  of  the  tumor  is  usually  so  large  as  to  allow  free  circula- 
tion through  the  bowel.  Gradual  loss  of  peristaltic  action  in 
the  bowel,  eventually  terminating  in  intestinal  obstruction,  is 
far  more  likely  to  occur. 

MECHANICAL    TREATMENT    OF    TRAUMATIC    VENTRAL    HERNIA. 

Many  cases  of  traumatic  ventral  hernia  seen  early  will 
show  very  satisfactory  results  under  mechanical  treatment. 
They  must  be  carefully  watched,  for,  like  cases  of  umbilical 
hernia,  there  is  in  them  a  strong  tendency  to  grow  worse  if 
not  kept  under  perfect  control.  Contrary  to  the  rule  in  umbil- 
ical hernia,  however,  they  not  infrequently  improve  very 
materially  under  the  use  of  mechanical  support,  and  I  have  seen 
a  few  that  have  been  cured  without  surgical  interference. 

If  the  surgeon  doubts  the  stability  of  his  abdominal  closure 
he  should  give  the  parts  support  either  by  a  truss  spring  to 
which  has  been  adjusted  a  suitable  pad,  or  with  a  general 
abdominal  belt  with  a  special  compress  arranged  over  the  line 
of  incision.  The  spring  is  always  best  where  the  wound  has 
been  on  either  side  of  the  median  line  and,  in  fact,  usually 
preferable  in  cases  of  median  incision.  The  effect  of  the  belt 
is  especially  good  in  some  cases  wlicre  there  is  great  tendency  to 
rapid  increase  of  fat.  as  it  undoubtedly  in  a  measure  checks  this. 
Good,  firm  support  must,  however,  be  afforded  by  a  surface 
that  is  not  so  conical  in  shape  as  to  force  itself  directly  into 
the  cicatrix. 


VENTRAL  HERNIA. 


393 


The  hard-rubber  cross-body  spring  made  for  the  treatment 
of  inguinal  hernia  has  frequentl}^  been  used  with  satisfaction. 
It  is  shaped  by  the  lead  tape  diagram  method  suggested  in 
the  chapter  on  the  mechanical  treatment  of  inguinal  hernia. 
Such  a  truss  is  shown  in  fig.  217,  applied  to  a  woman  sixty- 
five  years  old,  following  an  operation  for  an  abscess  case  of 


Fig. 


217. 


Woman  65  years  old,  with  ventral  hernia  following  operation  for  appendicitis,  retained  by 
hard-rubber  cross-body  truss,  with  ordinary  inguinal  pad. 


appendicitis,  where  drainage  was  necessary  for  many  weeks. 
Inguinal  springs  used  for  this  purpose  should  be  reduced  in 
pressure  considerably,  as  the  amount  required  is  much  less  than 
for  other  forms  of  hernia.  In  a  large  number  of  patients  the 
pad  used  in  inguinal  hernia  can  also  be  used  here,  as  shown. 
In  fact,  where  the  patient  is  rather  fat  it  is  better  than  the 
perfectly  flat  pads  made  by  most  truss-makers.  The  large  fiat 
pad  rests  upon  the  skin  and  subcutaneous  fat,  but  does  not 


394 


ABDOMINAL  HERNIA. 

Group  of  Trusses  for  Ventral  Hernia. 


I.    Elastic  ventral  hernia  truss.    Soft-  or  hard-rubber  pad. 


Hard-rubber  cross-body  spring  with  perforated  pad  for  ventral  hernia. 


^^ 


B  D  p  E 

3.    A  variety  of  pads  for  ventral  hernia. 


VENTRAL  HERNIA.  395 

Group  of  Trusses  for  Ventral  Hernia  {Continued). 


Hard  rubber 


4.    Laparotomy  belt,  with  hard-rubber  or  soft  compress. 


5.     Hood  truss.     Modified  for  ventral  hernia  on  right  side,  and  inguinal  on  left. 


6.     Cross-body  hard-rubber  ventral  hernia  truss  to  which  any  desired  form  of  pad  may 

be  attached. 


396  ABDOMINAL  HERNIA. 

reach  down  to  the  muscular  wall  where  the  difficulty  exists. 
In  young  and  thin  subjects  the  flat  pads  are  admirably  well 
adapted  for  the  purpose. 

In  enormous  protrusions,  such  as  shown  in  the  accom- 
panying illustrations,  nothing  short  of  a  well-made  and 
accurately-fitted,  strong  canvas  belt  will  give  the  general 
abdominal  support  that  is  demanded.  In  these  extreme  cases 
it  amounts  to  the  supplying  of  an  artificial  wall,  and  one  who 
has  not  had  experience  cannot  fully  appreciate  the  difficulties 
involved.  Patience,  perseverance,  and  many  refittings  will, 
however,  accomplish  a  great  deal,  and  when  we  consider  that 
it  is  in  just  this  class  of  cases  that  surgical  relief  is  almost  hope- 
less, the  importance  of  the  service  of  a  good  belt  maker  will  be 
more  fully  realized.  A  belt  used  after  an  abdominal  operation 
should  be  of  stout,  unstretching  material — not  elastic,  although 
this  is  often  inserted  to  save  trouble  in  fitting.  It  is  to  be  worn 
next  the  skin  and  straps  should  not  be  needed  under  the  thighs 
to  hold  it  down  or  make  it  comfortable.  This  will  ensure  the 
patient  using  it  as  directed. 

SURGICAL   TREATMENT   OF   TRAUMATIC   VENTRAL    HERNIA. 

No  hard  and  fast  rules  for  operating  upon  traumatic 
ventral  hernia  can  be  formulated,  nor  can  we  speak  of  its  sur- 
gical cure  with  the  same  degree  of  certainty  that  is  justifiable 
to  use  in  connection  with  other  forms  of  hernia.  Many  small 
protrusions,  where  the  muscles,  vessels,  and  nerves  have  not 
been  ruthlessly  cut,  can  be  permanently  cured  by  a  secondary 
operation. 

Cases  following  operations  for  appendicitis  are,  as  a  rule, 
quite  amenable  to  successful  treatment,  especially  if  the  incision 
has  been  pretty  well  out  toward  the  crest  of  the  ilium.  When 
the  internal  r)bHf|ue  muscle  has  been  divided,  its  outer  stump 
retracts  toward  Poupart's  ligament  and  rapidly  atrophies  so 
that  a  few  months  later  it  has  become  worthless  to  use  in 
closing  the  hernial  opening.  In  this  condition  the  only  hope 
of  making  an  efficient  closure  is  in  getting  out  freely  that  part 


VENTRAL  HERNIA.  397 

of  the  muscle  which  Hes  toward  the  median  Hue.  This  usually 
retains  a  fairly  normal  condition  and  if  freely  stripped  away 
from  the  aponeurosis  of  the  external  oblique  can  be  brought 
over  against  Poupart's  ligament  and  sutured  there  somewhat 
as  is  done  in  the  Bassini  operation  for  the  cure  of  inguinal 
hernia.  If  this  is  done  and  the  aponeurosis  of  the  external 
oblique  is  closed  tightly  over  it  a  cure  will  almost  certainly 
result. 

The  success  of  these  operations  depends  upon  freeing  the 
muscular  and  tendinous  layers  of  the  abdominal  wall  from 
adhesions,  and  then,  after  excising  as  much  as  possible  of  the 
cicatrical  tissue,  bringing  them  together  in  their  normal  rela- 
tions. Every  layer  should  be  sutured  independently.  The 
suture  material  used  by  the  author  has  been  no.  2  plain  catgut 
for  the  peritoneum,  kangaroo  tendon  for  muscular  and  tendi- 
nous structures,  and  where  possible  the  skin  has  been  closed 
subcutaneously  by  the  same  material  as  is  used  for  the  peri- 
toneum. 

The  overlapping  of  the  fascial  layers  may  sometimes  be 
used  to  advantage  in  these  cases.  The  bringing  together  of 
the  opening  edge  to  edge  is  of  little  use,  and  sutures  that 
require  considerable  tension  to  tie  will  soon  cut  through.  Dr. 
Carl  Beck  of  New  York  {Medical  Nezvs,  October  27,  1900) 
reports  a  case  that  seemed  hopeless  by  ordinary  means,  where 
he  obtained  a  cure  by  turning  out  a  flap  cut  from  the  rectus 
muscle  to  fill  in  the  gap  that  could  not  otherwise  have  been 
closed. 


CHAPTER  XXII. 
RARE  FORMS  OF  HERNIA. 

Lumbar  Hernia. — There  has  been  considerable  discussion 
as  to  the  exact  point  at  which  lumbar  hernia  leaves  the 
abdomen,  but  this  is  unimportant.  It  is  at  best  a  rare  con- 
dition, and  it  is  not  in  accord  with  the  intent  of  this  work  to 
enter  into  the  discussion  of  fine  points  that  are  of  no  practical 
value  to  the  general  practitioner. 

Whether  it  most  frequently  protrudes  at  Petit's  triangle  or 
Braun's  space  is  immaterial  to  its  proper  mechanical  or  surgical 
treatment.  Its  occurrence  is  very  rare,  only  4  cases  having 
been  seen  at  the  London  Truss  Society  up  to  1893,  the  total 
number  of  reported  cases  up  to  that  date  being  26,  according 
to  Macready. 

Lumbar  hernia  forms  a  tumor  in  the  lumbar  region  which 
may  vary  in  size  from  a  walnut  to  that  of  a  child's  head, 
and  presents  all  of  the  peculiar  characteristics  of  abdominal 
hernia  in  other  locations.  It  is  usually  reducible,  and  if  con- 
taining intestine  is  resonant  on  percussion  with  the  peculiar 
gurgling  sound  found  elsewhere.  It  may  be  spontaneous  or 
traumatic,  but  Borchardt  {Berliner  klinische  Wochenschrift, 
December  9,  1901)  divides  these  hernise  into  four  groups 
according  to  the  etiologic  factors  causing  them ;  those  of  trau- 
matic origin,  those  following  abscesses,  those  arising  spon- 
taneousl}^  without  any  known  cause,  and  the  congenital  lumbar 
hernia.  Out  of  43  lumbar  hernise,  he  has  collected  19  follow- 
ing injuries.  The  number  following  psoas  or  pelvic  abscesses 
which  break  in  this  region  is  comparatively  small,  and  no  doubt 
the  pointing  of  the  abscess  is  in  some  part  caused  by  the  natural 
weakness  of  the  abdominal  wall.  The  form  which  is  com- 
monly spoken  of  as  spontaneous  also  tends  to  occur  in  the 
region  known  as  Petit's  triangle.     Symptoms  of  strangulation 

398 


RARE  FORMS  OF  HERNIA. 


399 


are  of  comparatively  frequent  occurrence.  Ten  cases  of  this 
kind  have  been  reported.  In  5  of  these  the  strangulation  was 
of  a  transient  character.  The  case  shown  in  fig.  218  was  due 
to  congenital  defect  and  the  protrusion  occurred  on  both  sides, 


the  right  being  much  the  larger. 


The  treatment  mechanically  of  lumbar  hernia  is  attended 
by  considerable  trouble   on   account  of   its   peculiar   location 


Fig.  2i5 


Spontaneous  double  lumbar  hernia  due  to  defective  muscular  structure.  (Macready.) 

and  the  difficulty  in  securing  counter-pressure  for  the  truss- 
spring.  Abdominal  belts  with  a  compress  over  the  hernia 
may  be  useful,  but  a  spring  designed  by  Mr.  Kingdon  of  the 
London  Truss  Society  is  the  best  appliance  so  far  noted  in 
any  publication  (figs.  218  and  219).  The  base  of  action 
is  in  the  cushioned,  covered  plate,  held  in  position,  mid- 
way between  the  trochanter  and  the  crest  of  the  ilium,  by 
a  perineal  strap.  The  spring  attached  to  the  front  of  this 
plate,  by  ball  and  socket,  passes  obliquely  across  the  front  of 


400 


ABDOMINAL  HERNIA. 


the  abdomen  around  tlie  right  side,  and  holds  the  retaining  pad 
also  by  ball-and-socket  attachment.  From  this  point  a  strap 
passes  to  the  back  of  the  curved  plate  upon  which  it  buttons. 
Lumbar  hernise,  as  a  rule,  show  considerable  improvement 
under  ef^cient  mechanical  support,  and  some  cases  have  so  far 
improved  as  to  allow  of  the  abandonment  of  the  appliance. 

The    operative   treatment    of    lumbar    hernia   should   be 
carried  out  upon  the  same  general  principles  that  govern  the 

Fig.  219. 


Truss  lor  riyht  lumbar  hernia  designed  by  Mr.  Kingdon.    {Maci-eady.) 


surgical  treatment  of  ventral  hernia  in  other  locations.  This 
consists  in  the  enucleation  and  opening  of  the  sac,  the  reduc- 
tion of  its  contents,  the  ligation  of  the  neck,  and  finally  the 
closure  of  the  hernial  aperture.  The  overlapping  of  the  struct- 
ures to  secure  union  by  a  broader  surface  will  usually  be  found 
feasible  and  effective  in  this  region. 

Dr.  Chas.  N.  Dowd  of  New  York  has  recently  elaborated 
an  operation  {Annals  of  Surgery,  February,  1907,  p.  245)  for 


RARE  FORMS  OF  HERNIA.  401 

this  form  of  hernia  that  seems  commendable,  and  with  his  per- 
mission I  reproduce  his  cuts  which  ilhistrate  his  method  more 
clearly  than  words  could. 

The  child  shown  in  photograph  fig.  220  was  three  and  a 
half  years  old  and  had  worn  a  belt  without  improvement  for 

Fig.  220. 


Congenital  lumbar  hernia,  presenting  through  an  enlarged  triangle  of  Petit.    {Dowd.) 

two  years.  The  protrusion  was  the  size  of  a  goose  ^%%,  and 
at  operation  was  found  to  come  through  the  triangle  of  Petit. 
The  hernial  sac  was  distinct  but  without  a  narrow  neck. 
At  the  lower  end  of  the  protrusion  the  appendix  vermiformis 
was  found  and  removed :  "A  portion  of  the  sac  was  exsected, 
and  the  tissues  were  then  brought  together  from  the  sides;  the 
26 


402 


ABDOMINAL  HERNIA. 


margins  of  the  external  oblique  and  the  latissimus  dorsi  being 
drawn  together  as  far  as  possible.  After  this  was  done,  there 
was,  however,  a  triangular  defect  above  the  crest  of  the  illium. 
An  effort  was  made  to  close  this  in  with  an  aponeurotic  flap 
turned  up  from  below.     The  fascia  lata  and  the  aponeurotic 

Fig.  221. 


Congenital  lumbar  hernia  (i?owrf.)  ^,  transversalis  fascia;  .ff,  external  obliqus  muscle; 
C,  latissimus  dorsi  muscle;  Z*,  crest  of  ilium;  £,  gluteus  maximus  muscle;  /-",  gluteus 
medius  muscle. 


tissue  about  the  insertion  of  the  gluteus  maximus  and  medius 
formed  a  filjrous  layer  which  could  be  used  as  a  flap,  and  which 
was  turned  up,  having  the  attachment  at  the  crest  for  the  illium 
as  a  hinge.  This  was  stitched  in  place  with  chromic  gut, 
some  sutures  passing  through  the  previously  mentioned  trans- 
verse band,  some  through  the  edge  of  the  latissimus  dorsi,  and 


RARE  FORMS  OF  HERNIA. 


403 


others  through  the  edge  of  the  external  obHque  muscle.  There 
was,  however,  still  a  triangular  defect  above  the  flap,  and  this, 
together  with  the  repaired  area,  was  covered  by  turning  for- 
ward a  flap  cut  from  the  aponeurosis  of  the  latissimus  dorsi. 
This  was  stitched  to  the  external  oblique  "  (see  figs.  221,  222, 
and  223). 

Fig.  222. 


Operation  for  the  cure  of  cong-ential  lumbar  hernia  {Bowd)  .—Flap  composed  of  fascia 
lata  and  aponeurotic  part  of  gluteus  maximus  and  medius.  Stitches  placed  for  suturing  this 
flap  to  the  lumbar-fascia,  to  the  external  oblique  muscle  and  to  the  latissimus  dorsi  muscle 
and  for  drawing  the  upper  parts  of  the  latissimus  dorsi  and  external  oblique  together. 

Obturator  Hernia. — Obturator  hernia  presents  as  an 
obscure,  deep-seated  swelling  upon  the  thigh,  below  Scarpa's 
triangle.  It  is  rarely  recognized  until  strangulation  has 
occurred  or  until  after  death  has  taken  place.      Berger,   in 


404 


ABDOMINAL  HERNIA. 


examining-  10,000  cases  of  hernia  at  the  Paris  Central  Bureau, 
found  one  case  of  obturator  hernia.  It  leaves  the  pelvis 
through  the  obturator  canal  with  the  nerve  and  vessels  of  the 
same  name.  It  most  commonly  occurs  in  women  who 
have  passed  the  middle  age  of  life,  and  it  may  be  double. 
The  contents   of  the   sac  are   most   frequently  intestine,   but 

Fig.  223. 


Stitches  tied,  leaving  a  triangular  defect  above  the  Hap.     (Dowd.) 

the   Ijladder   and   uterine   appendages   have   also  been    found 
in  it. 

Franz  Schopf  (U^iciicr  Kliiiischc  U'ochcnsclirift,  Feb- 
ruar}^  19,  1903)  reported,  including  his  own  case,  5  cases  of 
protrusion  of  the  tube  and  ovary  in  obturator  hernia.  In  one 
the  uterus  was  included.  The  same  writer  states  that  during 
twenty  years  in  a  Vienna  hospital  in  393  cases  of  strangulated 
hernia  3  were  for  ol)turator  hernia. 


RARE  FORMS  OF  HERNIA.  405 

Diagnosis  is  seldom  made  until  strangulation  occurs  or 
after  an  autopsy  is  made.  The  tumor  is  more  easily  felt  than 
seen.  Macready  thinks  it  is  very  liable  to  be  overlooked  on 
account  of  faulty  methods  of  examination.  He  says,  "  It  is 
most  easily  approached  from  the  inner  side  of  the  thigh.  The 
thigh  must  be  flexed,  rotated  outwards,  and  carried  inwards  to 
relax  the  adductor  muscle,  and  the  finger  placed  against  the 
descending  ramus  of  pubes  behind  the  adductor  longus.  The 
finger  may  also  explore  the  inner  opening  of  the  obturator  canal 
from  the  vagina  or  rectum." 

The  treatment  of  this  form  of  hernia  has  not  been 
attended  by  success  and  84.4  per  cent,  of  those  operated  upon 
for  strangulation  have  died.  If  recognized  it  is  not  probable 
that  any  form  of  appliance  could  be  so  adjusted  as  to  give 
the  patient  any  degree  of  comfort  and  safety.  It  is 
beyond  question  that  the  safer  plan  for  the  patient  to  adopt 
would  be  an  attempt  to  effect  a  cure  by  operative  means 
and  the  approach  to  the  hernia  should  be  through  the 
abdomen. 

Sciatic  Hernia. — This  form  of  hernia  is  so  extremely 
rare  that  it  is  mentioned  only  to  call  attention  to  its  possible 
occurrence.  Its  name  indicates  its  location.  It  comes  through 
the  great  sacro-sciatic  foramen  and  its  contents  may  be  omen- 
tum, intestine,  ovary,  or  bladder.  Regarding  treatment  there 
has  been  little  suggested  that  would  be  of  real  service  to  the 
average  surgeon. 

Perineal,  ischio-rectal,  and  vaginal  hernize  all  pass  down 
through  the  pelvic  outlet  in  protruding  and  require  only  brief 
consideration  here.  All  hernise  that  protrude  through  the  pel- 
vic floor  properly  are  perineal  hernise,  but  they  have  been  given 
different  names  according  to  their  coverings.  If  they  push 
the  vaginal  wall  down  between  the  labia,  or  if  the  rectal  wall 
is  carried  down,  they  are  accordingly  called  vaginal  or  ischio- 
rectal. If  they  descend  in  the  wall  between  the  bladder  and  the 
rectum,  pushing  the  skin  before  them,  they  are  called  perineal 
hernia. 


406 


ABDOMINAL  HERNIA. 


These  hernire  have  their  origin  in  Douglas's  cul-de-sac 
and  may  be  caused  by  defective  development  of  the  muscular 
structure  of  the  pelvic  floor,  or  by  accidental  injury;  rarely 
where  no  such  cause  is  ascertainable,  they  have  been  called 
congenital.  They  occur  most  frequently  in  the  female.  In 
Macready's  collection  of  40  cases  only  6  were  in  the  male.  The 
contents  may  be  those  found  in  hernia  elsewhere,  but  are  be- 

FlG.  224, 


Woman  aged  30  years.    Exstrophy  of  bladder  and  vaginal  hernia. 

lieved  to  be  most  frequently  small  intestine.  The  sigmoid  flex- 
ure, the  bladder,  and  the  ovary  have  been  found.  In  the  female 
the  hernia  may  come  down  at  the  side  of  the  vagina  and  enter 
the  labia,  but  more  frequently  the  vaginal  wall  is  carried  down 
as  its  external  covering,  and  is  liable  to  be  mistaken  for  cysto- 
cele  or  labial  abscess.  They  may  also  protrude  either  at  the 
posterior  or  anterior  part  of  the  vaginal  entrance,  and  in  some 
instances  become  enormous  in  size  if  left  unattended. 


RARE  FORMS  OF  HERNIA. 


407 


The  case  shown  in  the  photograph  (fig.  224)  came  to  me  as 
a  private  patient  many  years  ago.  In  addition  to  the  enormous 
protrusion  there  shown,  which  contained  the  uterus,  ovaries, 
and  a  large  mass  of  intestine,  the  woman  suffered  from 
extrophy  of  the  bladder,  the  anterior  wall  of  that  organ  being 
entirely  absent.  The  appliance  designed  for  her  relief  is 
shown,   applied,   in  fig.   225.      It  consisted  of  a  steel   frame 

Fig.  225. 


Same  case,  with  supporting  appliances  on. 


arching  over  each  hip  and  resting  firmly  upon  the  crest  of  the 
ilium  of  either  side.  This  frame  held  a  large  hard-rubber  plate 
so  shaped  as  to  pass  over  the  pubic  bone  and  support  the  entire 
perineum.  This  served  the  double  purpose  of  retaining,  per- 
fectly and  comfortably,  the  pelvic  and  abdominal  contents  as 
well  as  protecting  the  patient  against  the  constant  wetting  with 
urine  that  dribbled  from  the  ureters.  The  urine  was  carried 
off  through  a  flexible  tube,  from  the  bottom  of  the  plate  to  a 


408  ABDOMINAL  HERNIA. 

rubber  bag  strapped  to  the  leg.  She  wore  this  apphance  at 
night,  as  well  as  during  the  day,  and  assured  me  that  for  the 
tirst  time  in  her  life  she  had  been  enabled  to  sleep  without 
being  wet  from  her  neck  to  her  feet. 

As  shown  by  the  foregoing  case,  perineal  hernia,  even  of 
enormous  proportions,  can  be  controlled  by  properly  designed 
supports.  Ordinarily  the  one  shower  in  fig.  226  answers  the 
purpose  very  well.  This  consists  of  a  metal  base  held  in  place 
over  the  sacrum  by  a  leather  belt  about  two  inches  wide.  To 
this  base  is  attached,  by  means  of  a  screw,  two  light  hard- 

FlG.  226. 


Appliance  for  perineal  ischio-rectal,  or  vaginal  hernia.     The  spring  comes  from  the  back  and 
may  have  attached  a  pad  of  any  desired  size  or  shape. 

rubber  covered  steel  springs.  The  inner  one  of  these  springs 
has  a  short  curve  and  should  terminate  at  about  the  centre  of 
the  intended  field  of  support.  To  this  spring  any  form  of  pad 
desired  may  be  attached.  The  outer  and  longer  spring  passes 
down  over  the  inner  one,  and  curving  forward  has  attached 
to  it  the  perineal  straps  that  come  up  in  front  and  are  buckled 
to  the  belt.  By  this  combination  of  the  tw^o  springs  the 
amount  of  pressure  to  be  used  can  be  very  accurately  adjusted. 
A  few  cases  of  vaginal  hernia,  if  detected  early,  may  be 
controlled  by  the  introduction  of  a  suitable  pessary,  but  such 
relief  is  very  likely  to  be  only  temporary.  Little  of  value  has 
been  written  upon  the  surgical  treatment  of  vaginal  hernia. 


CHAPTER  XXIII. 

CONTRA-INDICATIONS   TO    THE    SURGICAL    CURE 
OF  ABDOMINAL  HERNIA. 

There  are  certain  indications  which  should  cause  us  to 
hesitate  in  advising  the  operative  cure  of  hernia;  the  added 
danger  in  the  individual  case  may  be  greater  than  is  incurred  by 
the  continuance  of  the  disease. 

Excessive  fat  is  one  of  the  most  common  contra-indica- 
tions  in  people  of  middle  life.  It  is  particularly  bad  if  its 
accumulation  has  been  aided  by  heavy  beer  drinking,  which 
not  only  leads  to  the  production  of  excessive  fat,  but  causes  a 
corresponding  degeneration  of  muscular  tissue.  This  degen- 
erative change  is  quite  noticeable  in  the  abdominal  wall  and  is 
equally  present  in  the  heart  muscle.  When  such  conditions 
exist  operative  treatment  is  considered  dangerous  and  there 
is  more  liability  to  a  recurrence  of  the  hernia.  Still  it  may 
be  advisable  that  they  should  be  operated  upon,  owing  to 
rapidly  approaching  complete  disability  and  the  increasing- 
dangers  of  their  condition ;  either  they  or  their  friends  should 
be  told  of  the  danger  of  operation  and  the  probable  necessity 
of  wearing  good  support  for  a  year  or  longer. 

Ascites. — In  no  case,  except  as  a  life-saving  measure, 
should  an  attempt  be  made  to  cure  hernia  by  operation  in  any 
patient  who  has  an  excess  of  fluid  in  the  abdominal  cavity,  no 
matter  whether  this  be  temporary  and  trifling  or  serious  and 
permanent.  Such  patients  should  be  assured  that  no  danger 
attends  the  presence  of  the  fluid  in  the  hernial  sac  and  that  no 
operation  is  advisable  while  it  exists. 

Enormous  hernia  with  intestinal  adhesions  are  especially 
dangerous  for  operation,  owing  to  the  amount  of  handling  of 
the  bowel  and  the  intra-abdominal  pressure  to  which  it  is  sub- 
jected after  the  reduction  in  large  quantities.     Usually  these 

409 


410  ABDOMINAL  HERNIA. 

cases  can  be  recognized  before  operation  by  percussion,  after 
all  that  is  reducible  has  been  returned  to  the  abdomen.  If  the 
resonant  note  usually  found  over  the  bowel  is  obtained  it  will 
be  known  that  adherent  intestine  must  be  dealt  with. 

Tubercular  patients,  unless  in  an  advanced  stage,  stand 
the  operation  perfectly  well,  and  it  has,  in  the  author's  experi- 
ence, in  several  instances  seemed  advisable  to  operate  upon 
them,  and  he  has  had  no  occasion  to  regret  having  done  so. 

Age. — The  condition  of  the  patient  has  been  found  more 
important  as  a  contra-indication  than  advanced  age.  Old 
people,  if  organic  lesions  are  not  actually  present,  stand  the 
operation  well  and  are  not  particularly  liable  to  recurrence. 

In  all  of  these  cases  that  would,  in  insurance  phraseology, 
be  termed  extra-hazardous,  much  can  be  done  to  diminish  the 
danger  by  having  every  preparation  complete  for  doing  the 
work  as  rapidly  as  possible.  Assistants  and  nurses  should  be 
selected  and  coached  so  that  they  will  thoroughly  understand 
and  perform  their  various  duties  promptly.  The  anaesthetist 
should  always,  in  such  a  case,  be  a  person  of  admitted  judg- 
ment and  experience. 

ACCIDENTS  FOLLOWING  OPERATIVE  CURE  OF  HERNIA. 

Thrombosis  of  Femoral  Vein. — This,  fortunately,  is  an 
accident  that  very  rarely  follows  operation  for  the  cure  of 
abdominal  hernia,  yet  it  must  be  considered  as  one  of  the 
possible  accidents.  Goldner,  reporting  the  results  in  800  Bas- 
sini  operations  in  Prof.  Albert's  clinic,  Vienna  (Arch,  filr 
Klinische  Chinirgie,  Bond  Ixviii,  Heft  i,  1902),  states  that  3 
patients  died,  one  during  narcosis  and  2  from  embolism.  "  Both 
of  the  latter  had  large  varices  on  the  legs  and  this  condition 
should  impose  caution  in  doing  a  radical  operation." 

In  my  own  experience,  in  1,400  operations  for  abdominal 
hernia,  I  have  had  3  cases  of  thrombosis  of  the  femoral 
vein,  one  terminating  fatally  by  pulmonary  embolism.  The 
latter,  a  man  about  forty,  having  the  appearance  of  being  poorly 


CONTRA-INDICATIONS  TO  SURGICAL  CURE.  411 

fed  and  overworked  but  otherwise  apparently  in  good  health, 
was  operated  on  for  an  ordinary  complete  inguinal  hernia  on 
the  left  side.  The  time  required  was  about  twenty-five  minutes, 
and  nothing  occurred  to  which  the  subsequent  trouble  could  be 
traced.  Everything  appeared  favorable  up  to  the  seventh  day, 
at  which  time  he  began,  to  complain  of  extreme  pain  in  the  left 
leg,  and  evidence  of  thrombosis  was  plainly  visible.  Five  days 
later  pulmonary  symptoms  developed.  The  healing  of  the 
wound  was  primary  and  there  was  no'  varicose  condition  in  his 
case. 

The  two  other  cases  were  women  of  about  thirty-five  years. 
One  a  frail  woman  upon  whom  an  operation  for  right  femoral 
hernia  had  been  done  about  six  days  before,  developed  unmis- 
takable evidence  of  thrombus  in  the  left  leg.  The  operation 
(on  the  opposite  side)  had  been  a  very  simple  one  and  the 
wound  healed  completely  by  first  intention.  The  patient  was 
lame  for  three  months  and  then  recovered  perfect  use  of  the 
limb.  The  third  case  was  a  large,  healthy  woman,  operated  on 
for  supposed  irreducible  inguinal  hernia,  which  proved  to  be  a 
lipoma  protruding  from  the  canal.  This  was  removed  without 
difficulty  and  the  parts  healed  by  the  tenth  day  without  infec- 
tion. About  the  sixth  day  pain  developed  suddenly  and  the 
left  leg.  began  to  swell.  Troublesome  lameness  continued  for 
several  months. 

It  is  not  possible  to  discuss  the  cause  of  these  accidents 
here  as  in  reality  it  is  unknown.  They  are  liable  to  occur  in 
all  abdominal  and  pelvic  operations.  If  the  reader  wishes  to 
pursue  the  subject  he  is  advised  to  consult  the  excellent  article 
on  Embolism  by  Eugene  Boise  (Surgery,  Gyn.  and  Ohstr., 
July,  1906),  who  believes  that  it  never  occurs  in  a  normal  con- 
dition of  the  blood. 

Secondary  Hemorrhage  is  an  accident  seldom  known  in 
these  days  of  careful  ligation  of  vessels.  Its  most  serious 
occurrence  is  in  connection  with  the  ligation  of  omentum. 
These  vessels  have  no  surrounding  muscular  tissue  to  aid  in 
their  contraction,  and  if  the  ligature  is  inefficient,  or  slips  off, 


412  ABDOMINAL  HERNIA. 

the  bleeding  will  be  continuous  and  probably  fatal.  All  liability 
to  such  accident  can  be  guarded  against  by  careful  ligation  of 
indi\idual  vessels  unaccompanied  by  fat. 

Peritonitis  is,  with  aseptic  surgery,  practically  unknown 
in  operations  for  the  cure  of  abdominal  hernia.  Undue  trau- 
matism should  most  certainly  be  carefully  avoided. 

Sepsis. — General  sepsis  resulting  from  operations  for  the 
cure  of  hernia  is  now  extremely  rare,  but  the  occasional 
operator  should  realize  that  its  danger  is  always  present,  and 
that  for  its  occurrence  he  is  personally  responsible. 

INTERNAL    HERNIA. 

It  is  not  within  the  intent  of  this  work  to  consider  so-called 
internal  herni?e,  such  as  diaphragmatic,  hernia  of  the  foramen 
of  AVinslow,  of  the  duodeno-jejunal  recess,  of  the  inter-sigmoid 
recess,  or  retro-vesical  hernia  While  in  one  sense  these  belong 
to  the  subject  of  abdominal  hernia,  in  another  they  belong  to 
that  of  intestinal  surgery.  The  diagnosis  of  these  conditions 
is  very  rarely  made  before  operation,  frequently  not  until  the 
autopsv.  If  they  reach  the  surgeon  they  come  as  cases  of 
intestinal  obstruction,  with  little  evidence  that  the  bowel  may 
be  incarcerated  at  one  of  the  points  named. 


CHAPTER  XXIV. 
STRANGULATED  INGUINAL  HERNIA. 

Few  things  in  the  practice  of  medicine  are  more  alarming, 
not  only  to  the  patient  and  his  family  but  to  the  family  physi- 
cian, than  the  occurrence  of  strangulated  hernia.  A  tumor  which 
was  formerly  reducible  is  suddenly  found  hard,  tender,  painful, 
and  irreducible.  If  the  strangulation  is  acute  and  the  obstruc- 
tion complete,  the  agony  of  the  patient  is  beyond  description. 
That  which  was  a  few  minutes  before  considered  the  threaten- 
ings  of  a  mild  colic,  has  rapidly  advanced  to  a  degree  of  suf- 
fering toO'  great  for  human  endurance.  A  strong  man  will  cry 
out  like  a  child  in  the  intensity  of  his  suffering.  Shortly  vomit- 
ing intervenes  to  add  to  his  distress,  he  breaks  out  into  a  cold 
sweat,  and  if  aid  is  not  promptly  afforded  he  goes  into  a 
collapse  and  death  is  a  welcome  relief. 

Cause. — Volumes  have  been  written  discussing  various 
theories  as  to  the  cause  of  strangulation,  and  those  who  wish  to 
pursue  their  investigation  along  theoretical  lines  should  consult 
such  writings,  since  this  work  deals,  as  far  as  possible,  with 
facts.  Theory  is  of  little  interest  to  the  man  who  suddenly 
finds  himself  violently  sick,  nor  does  it  aid  the  attending  physi- 
cian in  this  emergency.  The  patient,  as  a  rule,  has  had  a 
hernia  for  several  years  and  has  known  how  to  replace  it,  but 
now  finds  this  impossible.  The  hernia  has  probably  become 
impacted  at  the  smallest  part  of  the  neck,  and  under  the 
pressure  of  this  impaction  the  normal  action  of  the  bowel  has 
been  checked.  Furthermore,  we  know^  full  well  that  while  the 
circulation  in  the  bowel  wall  may  not  have  been  completely 
shut  off  this  will  promptly  take  place,  with  consequent  destruc- 
tion of  all  tissues  under  constriction. 

In  cases  where  the  symptoms  gradually  reach  the  most 
distressing  stage,  it  is  probable  that  enough  of  the  protruding 

413 


414  ABDOMINAL  HERNIA. 

contents  is  forced  into  the  most  constricted  portion  of  the  sac  to 
impede  venous  circulation.  The  arteries,  whose  resistance  is 
greater,  continue  to  pump  blood  down  into  the  tumor,  but  the 
return  of  venous  blood  is  prevented  by  the  constriction.  Swell- 
ing and  effusion  of  fluid  then  take  place,  increasing  the  pressure 
until  finally  the  whole  mass  is  as  completely  shut  off  from  the 
cavity  of  the  abdomen  as  it  would  be  by  strong  ligature. 

Location  of  Stricture. — Many  times  it  cannot  be  told 
before  operating  where  the  constriction  will  be  found,  nor  is 
this  extremely  important.  In  hernia  of  the  congenital  variety 
it  will  in  many  instances  be  found  due  to  fibrous  rings.  These 
rings  are,  perhaps,  the  remains  of  nature's  attempts  to  carry 
out  her  original  design  of  obliterating  this  tubular  neck  between 
the  cavity  of  the  abdomen  and  cavity  of  the  tunica  vaginalis. 
Wliatever  may  have  been  their  origin,  they  are  tough,  inelastic, 
and  usually  situated  in  the  neck  of  the  sac  which  they  completely 
surround.  Sometimes,  however,  they  are  just  above  the  tes- 
ticle and  may  at  this  point  be  the  cause  of  constriction. 

In  the  greater  number  of  cases  of  strangulated  inguinal 
hernia,  the  constriction  is  at  or  near  the  external  ring  and  is 
caused  by  the  dense  and  strong  tissues  outside  of  the  sac  at 
this  point,  but  it  occasionally  happens  that  the  cause  of  strangu- 
lation is  within  the  sac  and  from  some  band  of  connective 
tissue.  This  is  usual  in  cases  of  old  hernise  of  large  size. 
Rarely,  it  will  have  its  origin  in  the  twisting  of  the  bowel  upon 
itself  within  the  sac,  or  more  frequently,  from  slipping  through 
a  hole  in  the  omentum  which  forms  a  part  of  the  hernia. 

Irreducibility  is  in  itself  no  evidence  of  strangulated 
hernia,  as  it  many  times  happens  that  those  who  have  large 
hernise  cannot  for  the  time  reduce  them,  either  from  the  quan- 
tity that  has  protruded  or  from  the  position  in  which  the 
contents  have  come  down ;  temporary  incarceration  results,  but 
no  accompanying  symptoms  of  strangulation.  No  immediate 
concern  need  be  felt  about  such  cases,  but  they  must  be  watched 
with  strictest  care,  as  they  are  on  the  borderland  of  strangu- 
lated hernia,  and  may  become  such  at  any  moment. 


STRANGULATED  INGUINAL  HERNIA.  415 

Such  tumors  are,  in  many  instances,  not  tense  or  hard, 
and  the  handHng  of  them  is  unattended  by  pain.  As  soon  as 
they  begin  to  get  hard  or  tender,  they  should  be  subjected  to 
immediate  operation.  It  is  very  seldom  that  a  hernia  becomes 
irreducible  from  its  outset  and  it  rarely  happens  that  strangula- 
tion takes  place  in  one  just  formed.  The  author  has  seen 
several  exceptions  to  this,  notably  one  just  operated  upon.  A 
young  woman,  in  stepping  from  a  car  "where  the  step  was  much 
higher  than  she  had  anticipated,  felt  an  immediate  pain  in  the 
left  groin.  Shortly  afterward,  acute  abdominal  pain  and 
vomiting  came  on,  and  it  was  discovered  that  she  was  suffering 
from  a  femoral  hernia  in  a  state  of  strangulation. 

Physical  Signs. — One  of  the  physical  signs  of  inguinal 
hernia,  recently  strangulated,  is  a  tumor  of  variable  size  any- 
where in  the  inguinal  region  or  the  scrotum.  It  feels  hard, 
especially  toward  the  point  where  its  neck  enters  the  abdomen. 
If  the  symptoms  are  acute  it  may  have  the  elastic  feel  of  fluid, 
as  effusion  rapidly  occurs  under  tight  constriction.  Discolora- 
tion of  the  surface  seldom  takes  place  until  very  late,  and  is 
then  more  frequently  the  result  of  violent  handling  than  from 
other  causes. 

It  must  be  borne  in  mind  that  the  appearance  of  the 
surface  is  no  indication  whatever  of  the  condition  of  the  parts 
within.  There  is  likely  to  be  heat  after  the  strangulation  has 
lasted  for  some  hours,  but  not  in  the  earlier  stages.  It  should 
also  be  remembered  that  an  inflamed  hydrocele,  either  in 
the  scrotum  or  encysted  in  the  inguinal  canal,  may  be  deceptive, 
but  neither  will  be  accompanied  by  general  symptoms  of 
strangulation.  (This  also  applies  to  inflamed  hydrocele  in  the 
canal  of  Nuck  in  the  female.  The  latter  is  more  likely  to  be 
confusing  since  many  physicians  are  not  aware  that  hydrocele 
occurs  in  the  female.)  A  case  was  seen  by  the  author  in  con- 
sultation, wdiere  all  the  physical  signs  of  strangulated  hernia 
were  present — that  is,  a  small  tumor  in  the  inguinal  region, 
extremely  sensitive,  and  wnth  a  history  of  hernia  and  truss- 
wearing.     To  add  to  the  obscurity  of  the  case  the  patient  had 


416  ABDOMINAL  HERNIA. 

felt  that  he  might  vomit  at  any  moment,  although  he  had  not 
clone  so.  He  was  sick  only  when  the  tumor  was  handled.  It 
proved  to  be  a  case  of  orchitis  in  a  testicle  which  had  never 
reached  its  destination  in  the  scrotum. 

SYMPTOMS. 

Pain, — It  almost  invariably  happens  that  the  very  first  pain 
experienced  from  strangulated  inguinal  hernia  is  not,  as  w^ould 
be  expected,  at  the  point  of  stricture,  nor  even  in  the  region  of 
hernia,  but  in  the  vicinity  of  the  umbilicus — an  ill-defined, 
colicky  pain  that  is  likely  to  lead  the  patient  to  believe  that  he 
has  eaten  something  which  is  disagreeing  with  him.  This  may 
increase  to  an  extreme  pain  without  local  symptoms  to  lead  the 
patient  to  examine  his  hernia,  but  in  most  instances  there  occurs 
more  or  less  discomfort  in  the  inguinal  region,  and  the  true 
condition  of  the  swelling  is  discovered.  The  pain  increases  in 
intensity  with  more  or  less  rapidity,  according  to  the  acuteness 
of  stricture,  and  it  is  paroxysmal,  appearing  at  times  to  have 
left  the  patient  entirely  and  then  returning  with  renewed  force. 
This  undoubtedly  corresponds  with  the  peristaltic  action  of  the 
bowel  which  makes  endeavors  with  increasing  violence  to  free 
itself.  If  at  this  point  the  physician  steps  in  and  relieves  the 
pain  by  a  hypodermic  injection  of  morphine,  the  patient's  mind 
is  also  entirely  relieved,  but  the  pathological  changes  go  on 
uninterruptedly  and  the  man  is  rapidly  advancing  to  his  death. 
The  pain  is  described  by  the  patient  as  a  most  terrible  distress 
rather  than  a  pain,  and  it  usually  extends  over  the  entire, 
abdomen. 

The  following  cases  illustrate  in  a  striking  manner  how 
little  dependence  can  be  placed  upon  the  location  of  pain  in 
strangulated  hernia.  A  woman,  seventy-five  years  of  age,  with 
valvular  lieart  trouble  and  otlierwise  not  in  good  general  condi- 
tion, developed  extreme  abdominal  distress,  which  was  soon 
followed  bv  vomiting  and  comjjlete  intestinal  obstruction.  The 
familv  i)livsician  saw  the  case  on  the  first  day  and  discovered 
that  she  had  small  hernine  in  both  the  umbilical  and  femoral 


STRANGULATED  INGUINAL  HERNIA.  417 

regions,  but  the  patient  assured  him  that  there  was  no  notice- 
able change  in  these  swelhngs.  Both  had  existed  for  several 
years  and  neither  had  been  reducible  for  a  long  time.  Local 
symptoms  were  entirely  lacking.  Hypodermics  made  a  doubt- 
ful case  still  more  obscure,  as  temporarily  they  relieved  the 
pain.  On  the  third  day  the  case  was  seen  by  the  author  in 
consultation.  It  was  at  once  decided  that  one  of  the  hernias 
was  in  trouble,  and  an  immediate  operation  was  strongly 
urged.  There  was  no  guide  as  to  wdiich  hernia  should  be 
operated  upon,  except  that  femoral  hernia  is  more  liable  to 
strangulation  than  the  umbilical  variety.  Ether  was  given  and 
a  loop  of  small  bowel  was  found  caught  under  Poupart's  liga- 
ment in  the  femoral  canal.  The  bowel  was  in  bad  condition, 
but  after  applying  hot  cloths  for  half  an  hour,  it  was  returned 
to  the  abdomen.     The  patient  made  a  perfectly  good  recovery. 

In  hernise  that  have  been  long  strangulated,  the  bowel 
after  a  time  becomes  paralyzed  or  gangrenous  and  the  pain  in 
a  measure  subsides.  Distention  ensues  and  the  patient  is  very 
likely  to  die,  even  if  an  operation  is  performed.  This  remark 
must  not  be  taken  as  intimating  that  the  operation  should  not 
be  done  even  in  the  most  desperate  case.  Death  is  absolutely 
certain  without  it,  and  cases  apparently  moribund  are  not  infre- 
quently saved  by  it. 

Vomiting. — The  vomiting  in  strangulated  hernia  is  doubt- 
less reflex  in  character  and  may  begin  within  a  few  moments 
of  the  strangulation  or  may  be  delayed  for  several  hours.  It  is 
perhaps  the  most  important  symptom.  If  a  portion  of  the 
bowel  high  up  in  the  intestinal  tract  is  involved,  it  is  very  likely 
to  come  on  early,  but  this  also  depends  somewhat  upon  the 
tightness  of  the  constriction.  It  is  quite  certain  that  in  cases 
involving  the  large  bowel  vomiting  is  very  likely  to  be  delayed. 
The  contents  of  the  stomach  are  first  vomited  and  later  the 
contents  of  the  small  intestine,  when  the  characteristic  fecal 
odor  is  presented.  In  former  years  it  was  considered  good 
practice  not  to  operate  for  strangulated  hernia  until  stercora- 
ceous  or  fecal  vomiting  had  occurred.     It  is  not  surprising 

27 


418  ABDOMINAL  HERNIA. 

that  few  recovered  after  operation,  and  to-day  such  waiting 
would  be  plainly  criminal. 

Pain  and  vomiting-  usually  indicate  the  severity  of  the  case 
and  the  urgent  need  of  haste.  If  the  symptoms  are  violent 
prompt  relief  must  be  afforded  or  the  patient  will  die.  It  hap- 
pens rarely  that  complete  destruction  of  the  bowel  coats  have 
taken  place  without  vomiting  having  been  present.  The  cessa- 
tion of  vomiting  in  a  given  case,  after  having  existed  for  some 
time,  is  a  most  grave  symptom,  and  usually  denotes  complete 
collapse,  or  paralysis  of  the  bowel,  either  of  which  is  pretty  cer- 
tain to  lead  to  a  fatal  termination. 

Constipation  is  usually  complete.  In  a  fairly  good  pro- 
portion of  the  cases  there  will  be  one  movement  of  the  bowels 
after  strangulation  has  taken  place,  the  lower  bowel  merely 
emptying  itself.  There  may  be  tenesmus  and  frequent  desire 
and  the  feeling  that  a  movement  is  about  to  occur.  Cathartics, 
by  increasing  peristalsis  and  vomiting,  merely  add  to  the  suf- 
ferings of  the  patient,  and  should  never  be  given.  Eructa- 
tions and  hiccough  are  frequently  early  and  persistent 
symptoms. 

There  is  one  exception  to  constipation  as  a  symptom,  and 
that  is  in  a  case  of  partial  enterocoele,  which  will  be  referred  to 
a  little  later. 

Thirst  is  intense,  and  if  indulged  the  fluid  is  at  once 
rejected  by  the  stomach. 

The  Pulse  is  many  times  an  important  aid  in  deciding  as 
to  the  severity  of  a  given  case  of  strangulated  hernia,  and 
impending  collapse  is  first  indicated  by  changes  in  it.  The 
grave  character  of  a  case  may  be  indicated  by  it  where  other 
symptoms  are  not  very  prominent. 

Temperature. — It  is  surprising  how  many  physicians  make 
the  mistake  of  supposing  that  so  long  as  there  has  been  no 
elevation  of  temperature  the  case  is  not  in  great  danger.  The 
truth  is  that  there  is  more  frequently  subnormal  temperature 
than  elevation.  A  neglected  case  which  has  developed  general 
peritonitis  may  have  elevation  of  temperature,  but  more  die  in 


STRANGULATED  INGUINAL  HERNIA.  419 

collapse  without  ever  reaching  that  stage.  Ordinarily  there  is 
little  change  of  temperature  throughout  the  case,  and  it  is 
important  only  when  subnormal,  which  indicates  the  need  for 
haste  in  the  preparations  for  relief. 

Respiration  is  almost  always  hurried,  until  the  patient  is 
passing  into  a  condition  of  stupor,  when  it  may  become  slow 
and  stertorous. 

Collapse  may  come  on  almost  immediately  after  strangu- 
lation has  taken  place,  or  may  be  delayel  for  several  hours.  It 
is  at  any  time  a  very  grave  symptom,  and  has  been  considered 
by  some  inevitably  fatal. 

That  it  is  not  universally  fatal,  the  author  has  had  several 
illustrations.  In  one  case,  that  of  a  man  nearly  eighty  year.s 
of  age,  who  was  apparently  in  complete  collapse  and  about  to 
die,  with  strangulation  for  about  three  days,  the  operation  was 
done  without  an  anaesthetic,  as  he  was  in  a  stupor.  The  bowel 
was  found  in  bad  condition,  but,  under  the  application  of  hot 
towels,  showed  evidence  of  recovery  and  was  returned  to  the 
abdomen.  The  patient's  condition  improved  before  the  opera- 
tion was  completed,  and  he  made  a  slow  but  complete  recovery. . 
It  has  been  noticed  in  several  instances  that  the  pulse,  respira- 
tion, and  general  condition  begin  to  improve  shortly  after  the 
constriction  is  cut.  It  is  also  believed  that  the  hot-water  appli- 
cations which  have  been  sO'  frequently  used  in  these  severe 
cases,  acts  as  a  stimulant  to  the  patient.  In  one  patient  recently 
operated  upon,  collapse  came  on  again  after  there  had  been 
general  improvement  during  the  operation,  and  the  woman 
came  very  near  dying  on  the  table. 

An  otherwise  healthy  woman,  sixty-eight  years  of  age,  suf- 
fering from  an  inguinal  hernia  on  the  right  side,  placed  herself 
in  the  hands  of  one  of  the  quack  firms  that  promised  to  cure 
hernia  by  hypodermic  injection.  The  first  two  injections,  an 
interval  of  one  week  between,  were  fairly  painful,  but  were 
tolerated  w^ithout  much  complaint ;  the  third,  however,  pro- 
duced the  most  excruciating  pain  and  prevented  her  leaving 
the  bed  on  the  following  day.     She  grew  rapidly  worse  and 


420  ABDOMINAL  HERNIA. 

began  to  vomit,  and  her  family  physician  came  in  and  admin- 
istered opiates.  On  the  morning  of  the  second  day  consuha- 
tion  was  cahed,  and  the  case  pronounced  strangulated  hernia, 
and  was  sent  to  the  author  for  operation.  When  she  arrived  at 
the  private  hospital  she  was  in  partial  collapse,  with  the  whole 
body  bathed  in  cold  perspiration,  and  suffering  from  the  most 
agonizing  pain.  Preparations  were  cjuickly  made  and  the 
operation  begun.  Her  daughter  was  informed  that  death 
might  occur  before  the  operation  w^as  completed. 

Upon  opening  the  parts,  it  was  found  that  the  injection  for 
the  so-called  "  cure ''  of  hernia  had  been  through  the  neck  of 
the  sac  into  the  coat  of  the  bowel,  and  the  violent  inflammation 
following  had  resulted  in  a  complete  stricture  of  the  bowel. 
The  bowel  was  adherent  in  the  canal,  but  it  could  not  be  decided 
positively  whether  this  adhesion  was  due  to  the  injection,  or 
had  previously  existed.  After  the  constriction  had  been  cut 
and  hot  applications  made  to  the  bowel,  the  patient's  condition 
improved  rapidly,  but  just  as  she  was  about  to  be  transferred  to 
the  bed  it  was  discovered  that  she  had  again  gone  into  a  state 
of  collapse  so  complete  that  at  one  time  she  was  thought  to  be 
dead.  After  an  hour's  work  with  the  use  of  oxygen, 
stimulants,  and  hot  saline  solutions  under  the  skin  and  per 
rectum,  she  was  restored  and  made  a  complete  and  rapid 
recovery. 

This  case  has  been  given  somewhat  at  length,  as  contain- 
ing several  illustrative  points. 

1st. — That  the  injection  of  irritants  about  the  canal  may  cause 
death. 

2nd. — That  strangulation  maj^  be  secondary  to  an  earlier  inflam- 
mation. 

3rd. — That  patients  may  suffer  and  even  die,  from  the  recurrence 
of  the  symptoms  of  collapse. 

4th.  — That  it  is  not  best  to  abandon  too  early  efforts  at  restora- 
tion of  a  patient  in  collapse. 

Collapse  may  come  on  so  early  and  violently  in  cases  of 
strangulated  hernia,  as  to  cause  the  death  of  the  patient  before 


STRANGULATED  INGUINAL  HERNIA.  421 

it  is  possible  to  afford  relief.  The  amount  of  injury  to  the 
bowel  cannot  be  estimated  by  the  degree  of  collapse  in  which 
the  patient  is  found.  In  some  cases,  when  death  has  occurred 
early,  the  bowel  has  not  been  found  badly  damaged.  Collapse 
and  death  must,  in  these  cases,  come  wholly  from  reflex  action. 
In  cases  long  neglected,  where  fecal  vomiting  has  existed  for 
some  time,  poisoning  may  occur  from  this  source  and  death 
result  either  before  or  after  the  operation.  It  is  in  cases  of 
just  this  character  that  general  anaesthesia  should^  if  possible, 
be  avoided,  as  it  adds  to  the  depression  which  already  exists, 
and  there  is  also  liability  of  the  patient  drawing  into  the  lungs, 
by  inhalation,  the  poisonous  fluids  which  are  being  constantly 
vomited.  Convulsions  are  not  uncommon  as  an  early  symptom 
in  young  children,  and  they  may  occur,  though  very  rarely,  in 
the  adult. 

Peritonitis,  Local  and  General. —  In  almost  every  instance 
of  strangulated  hernia,  some  indications  of  localized  peritonitis 
will  be  found,  even  though  the  case  may  have  been  of  only  a 
few  hours'  duration.  This  may  consist  merely  of  the  exudation 
of  a  little  plastic  lymph,  which  glues  the  protruding  contents  to 
the  side  of  the  sac,  or  a  quite  active  peritoneal  inflammation, 
extending  in  every  direction  from  the  point  of  the  constriction. 
It  is  believed  that  death  more  frequently  results  from  shock 
due  to  pressure  on  constricted  bowel  than  from  general  perito- 
nitis. The  latter,  however,  does  occur,  and  when  it  is  present 
the  prognosis  must  be  of  the  gravest  character.  Again,  it  will 
be  urged,  however,  never  to  abandon  a  case  no  matter  how 
hopeless  it  may  appear.  Better  give  the  patient  his  only  chance 
of  life,  even  though  he  die  on  the  table. 

General  peritonitis  may  develop  from  the  point  of  constric- 
tion, following  the  peritoneal  surface,  or  it  may  be  communi- 
cated from  the  bowel,  which  is  enormously  distended  above  this 
point.  From  the  latter  cause  it  may  become  general,  either 
before,  or  after  the  operation.  Perforation  of  the  bowel  into 
the  peritoneal  cavity  is  usually  followed  by  immediate  collapse 
and  early  death. 


422  ABDOMINAL  HERNIA. 

Where  there  is  extreme  abdominal  distention,  the  prog- 
nosis is  always  bad,  as  it  frequently  indicates  complete  paralysis 
of  the  bowel  above  the  point  of  constriction.  In  such  patients 
one  or  more  normal  evacuations  may  occur  after  the  operation, 
and  then  the  symptoms  of  intestinal  obstruction  are  again  pre- 
sented and  the  patient  dies.  The  operator  is  quite  liable  under 
such  conditions  to  think  that  he  has  failed  to  remove  all  con- 
strictions of  the  bowel  at  the  time  of  the  operation,  when  in 
reality,  the  cause  of  death  has  been  complete  paralysis  of  the 
over-distended  bowel. 

Partial  Enterocele. — This  form  of  hernia  is  where  one 
coat  of  the  bowel  has  been  caught  and  strangulated,  but  the 
entire  lumen  has  not  been  occluded.  The  fibrous  rings  which 
•frequently  form  in  hernial  sacs  have  been  previously  alluded 
to,  and  into  a  ring  of  this  character  such  a  hernia  may  protrude 
and  become  strangulated.  This  form  of  hernia  has  frequently 
been  referred  to  as  Lavaters,  Littres,  and  Richter's  hernia. 
Diagnosis  is  obscure,  from  the  fact  that  a  very  small  tumor,  if 
any,  can  be  found,  and  also  that  there  is  not  complete  obstruc- 
tion of  the  bowel.  It  not  infrequently  occurs  that  there  is  a 
tendency  to  diarrhoea.  The  pain  is,  however,  characteristic 
and  similar  to  that  found  in  other  forms  of  strangulated  hernia ; 
that  is,  coming  in  paroxysms  with  intervals  of  relief.  The  dis- 
tention found  in  other  cases  is  not  usually  present,  and  the 
stools  are  occasionally  bloody. 

It  is  seldom  that  such  cases  can  be  relieved  except  by 
operation,  and  the  following  case  indicates  their  deceptive  char- 
acter: A  man,  twenty- four  years  of  age,  had  left  inguinal 
hernia  since  early  childhood,  and  had  never  worn  a  truss. 
Symptoms  of  strangulation  occurred  five  days  before  he  was 
seen  by  the  author,  vomiting  beginning  on  the  second  day. 
An  operation  was  done  on  that  day  by  the  attending 
])hysician,  who  opened  down  to  the  external  ring,  incising  a 
distended  sac  of  the  congenital  variety.  From  this  consider- 
able dark-colored  fluid  escaped,  but  otherwise  it  appeared 
empty.     As  the  finger  could  ht  passed  freely  in  either  direction. 


STRANGULATED  INGUINAL  HERNIA.  423 

he  assumed  that  the  hernia  had  been  reduced  under  ether,  and 
closed  the  parts.  As  later,  symptoms  increased  in  severity,  the 
author  was  called  to  see  the  case  three  days  after  the  operation. 
Marked  evidence  of  intestinal  strangulation  was  present. 
Extreme  pain  was  masked  somewhat  by  the  free  hypodermic 
use  of  morphia.  The  man  had  a  dusky  skin,  was  becoming 
stupid,  had  a  distended  abdomen,  and  a  weak  heart. 

The  wound  was  re-opened  and  the  canal  split  to  the 
internal  ring.  A  knuckle  of  _  small  intestine  was  found 
imprisoned  just  at  the  upper  end  of  the  canal,  and  as  the 
stricture  was  divided,  the  gut  dropped  back  into  the  abdomen. 
By  enlarging  the  opening  somewhat,  and  making  gentle  press- 
ure upon  the  abdominal  wall  above,  it  was  obtained  again  and 
brought  outside  for  inspection.  The  anterior  wall  of  the  bowel 
had  been  under  sharp  constriction,  but  its  mesenteric  attach- 
ments had  not  been  under  pressure,  so  that  the  circulation  of 
the  posterior  surface  had  been  maintained.  The  bowel  was 
dark  and  edematous,  but  under  the  application  of  hot  water  a 
change  of  color  was  noticeable,  and  it  was  returned  to  the 
abdomen.     The  man  made  a  prompt  recovery. 

Where  we  have  acute  symptoms,  showing  us  that  the 
intestine  is  involved,  it  is  desirable  that  we  should  see  the  bowel 
in  order  to  decide  whether  or  not  is  is  safe  to  return  it  to  the 
abdominal  cavity. 

Inflamed  Glands,  occurring  in  those  who  have  been 
known  to  have  suffered  from  hernia,  may  cause  considerable 
obscurity  in  the  diagnosis.  It  will  at  once  be  seen,  by  lack  of 
general  abdominal  symptoms,  that  the  intestine  is  not  involved, 
but  it  is  not  so- easy  to  decide  that  a  tumor  may  not  be  a  mass 
of  inflamed  omentum.  We  almost  invariably,  however,  have  a 
few  abdominal  symptoms  where  the  incarceration  involves 
omentum  exclusively. 

Orchitis  in  Retained  Testicle  or  Torsion  of  Cord  may 
cause  some  confusion  in  diagnosis  with  physicians  who  do  not 
see  many  cases  of  this  character.  The  table  of  Eccles 
("  Imperfectly  Descended  Testis,"  W.  McAdam  Eccles,  M.S., 


424 


ABDOMINAL  HERNIA. 


F.R.C.S.,  Wm,  Wood  &  Co.,  1903)  is  so  sug-gestive  that  it  is 


thought  best  to  introduce  it  here. 


Differential  Diagnoses  of  Torsion  of  Spermatic  Cord,  Strangu- 
lated Hernia  and  Acute  Lymphadenitis. 


1 

Torsion  of  Cord. 

Strangulated  Hernia. 

Lymphadenitis. 

History 

Position  of  testis 

Shock  

Probable  of  strain. 

Often  imperfectly  de- 
scended. 

Moderate. 

Slight  and  not  persist- 
ent. 

May  be  present. 

Is'ot  marked. 

May  be  expansible  if 

hernia  be  present. 
May  be  felt  twisted. 

Often  of  strain. 
Usually    fully    de- 
scended. 
Often  severe. 
Severe  and  persistent. 

Is  absolute. 
Marked. 

No  expansible  impulse 

Obscured. 

Of  infection. 
Usually    fully    de- 
scended. 

Induration  or  fluctua- 

Impulse on  cough  . . . 
Condition  of  cord  . . . 

tion. 
No  expansible  impulse. 

Normal. 

The  lodgment  of  a  testicle  in  the  inguinal  canal  is  quite 
liable  to  be  mistaken  for  strangulated  hernia.  Reference  has 
already  been  made  to  such  a  case  seen  in  consultation,  where 
two  physicians  had  failed  to  recognize  the  true  condition. 
The  error  is  quite  excusable  on  account  of  nausea  and  vomiting 
frequently  present  in  this  condition.  Intestinal  obstruction  is 
not  present,  however,  and  the  character  of  the  pain  is  quite 
different  from  that  present  when  the  bowel  is  strangulated.  In 
the  latter  condition  the  pain  is  intermittent,  corresponding  with 
the  violent  peristalsis,  while  in  orchitis  there  is  an  intense,  dull, 
sickening  pain  which  is  constant.  The  onset  of  the  pain  is 
usually  quite  different,  that  of  strangulated  bowel  being  sudden 
and  rather  violent  in  character  from  the  first ;  in  orchitis  there 
is  usually  a  history  of  traumatism  with  gradual  increase  of  the 
symptoms.  The  absence  of  the  testicle  from  the  scrotum 
should  also  cause  suspicion  as  to  the  true  cause  of  the  trouble. 

Scrotal  Hernia  of  Enormous  Size. — In  these  cases  symp- 
toms of  strangulation  are  seldom  of  tlie  acute  variety.  Usually 
they  contain  large  masses  of  omentum,  and  the  protrusion  of 
the  bowel  inside  is  somewhat  protected  from  extreme  pressure 
even  though  it  may  be  strangulated.  If  the  contents  of  these 
larger  herni?e  should  be  exclusively  omentum,  the  symptoms 


STRANGULATED  INGUINAL  HERNIA.  425 

will  then  be  more  of  an  inflammatory  character,  and  under 
rest  and  cold  applications  may  subside  without  operation.  On 
the  contrary,  however,  if  the  constriction  is  very  tight,  slough- 
ing of  the  omental  mass  may  occur,  seriously  complicating  the 
case. 

A  case  of  this  character  which  had  been  five  weeks  under 
treatment  was  brought  to  the  author  from  a  distant  city.  Dur- 
ing most  of  this  time  the  man  had  been  in  bed  and  applications 
of  hot  olive  oil  had  been  made  to  the  tumor.  Upon  operation 
it  was  not  only  found  that  the  omentum  in  the  scrotum  was 
about  to  slough,  but  that  the  entire  omentum,  above  as  well 
as  below  the  point  of  constriction,  was  involved.  This  omen- 
tum was  inflamed,  thickened,  and  attached  to  the  peritoneal 
surface,  so  that  it  was  necessary  to  leave  it  in  about  the 
condition  found,  although  that  portion  in  the  scrotum  was 
removed  and  the  abdomen  closed.  The  wound  closed  by 
primary  union,  but  it  was  found  at  the  end  of  the  second 
week  after  the  operation  that  general  abdominal  trouble  was 
increasing.  A  hard  tumor  had  formed  nearly  on  a  level  with 
the  umbilicus  and  about  three  inches  to  the  outer  side.  An 
incision  was  made  into  this,  and  for  nearly  three  weeks  slough- 
ing omentum  was  discharged,  but  the  man  eventually  made  a 
good  recovery. 

Strangulation,  occurring  in  hernije  of  enormous  size,  is 
frequently  preceded  by  a  long  term  of  obstinate  constipation, 
finally  terminating  in  complete  intestinal  obstruction.  Such 
cases,  unless  operated  on  very  early,  are  quite  sure  to  prove 
fatal,  as  they  have  their  origin  in  the  paralysis  of  the  loop, 
or  loops,  of  bowel  which  have  formed  the  contents  of  the 
hernia.  The  bowel,  being  held  by  adhesions,  has  gradually  lost 
its  peristaltic  power,  and  when  paralysis  has  resulted  symptoms 
of  intestinal  obstruction  are  presented.  Such  cases  do  well 
for  a  few  days  after  the  operation,  when  intestinal  obstruction 
again  comes  on  and  the  patient  dies.  In  these  large  herniae, 
strangulation  may  occur  by  bands  of  connective  tissue  which 
hold  the  bowel  at  an  acute  angle.     At  the  time  of  the  operation. 


426  ABDOMINAL  HERNIA. 

such  bowel  will  be  found  in  perfectly  normal  condition,  but 
doubled  upon  itself,  in  such  a  manner  that  its  lumen  is 
occluded. 

Children. — As  a  general  rule,  the  symptoms  of  strangula- 
tion in  young  children  are  not  quite  so  violent  and  acute  as 
in  older  persons,  nor  is  the  occurrence  of  strangulation  attended 
by  quite  the  same  amount  of  danger.  Many  cases  of  tem- 
porary incarceration  have  been  seen  in  children  under  treat- 
ment by  mechanical  means,  with  little  indication  of  pain  or 
intestinal  obstruction,  yet  the  hernia  was  hard  and  irreducible. 
Such  cases,  of  course,  require  close  watching,  but  an  early 
operation  is  not  necessarily  indicated.  The  author  has,  in  a 
number  of  instances,  sent  the  mother  home  with  the  child  in 
this  condition,  with  instructions  to  make  gentle  pressure  over 
the  tumor  when  the  child  was  asleep ;  in  almost  every  instance 
this  has  proven  sufficient  to  cause  its  reduction.  With  careful 
and  proper  manipulation  cases  demanding  immediate  relief  can 
generally  be  reduced  while  the  child  is  under  chloroform. 

The  author  has  never  seen  a  case  of  strangulated  hernia 
in  infancy  that  he  could  not  reduce  under  chloroform  by  care- 
ful manipulation,  but  he  freely  admits  that  such  cases  may 
occur.  Even  more  care  must  be  observed  than  in  handling  the 
adult,  owing  to  the  greater  delicacy  of  the  structures.  Force 
that  would  be  allowable  in  the  adult  would  be  violence  if  used 
on  an  infant.  After  such  hernise  have  been  reduced  it  is  not 
uncommon  for  the  child  to  have  one  or  more  bloody  stools. 


CHAPTER  XXV. 

MEDICAL  TREATMENT  OF  STRANGULATED 
HERNIA. 

Perhaps  the  very  best  way  to  discuss  this  branch  of  the 
subject  is  to  state  at  once  that  there  is  no  medical  side  to  the 
treatment  of  strangulated  hernia,  leaving  the  subject  there.  To 
many  this  would  doubtless  appear  dogmatic ;  on  the  other  hand, 
there  is  reason  to  treat  of  the  medical  side  in  order  to  show  its 
dangers.  Certain  it  is  that  medication  is  time-consuming,  and 
therefore  dangerous,  and  should  be  avoided  in  almost  every 
case. 

The  literature  of  the  subject  is  not  lacking  in  the  number 
of  remedies  which  have  been  recommended  in  these  cases. 
Large  doses  of  atropine,  opiates,  and  other  drugs,  as  well  as 
strong  decoctions  of  coffee,  have  been  recommended.  Atropine 
and  morphine  have  been  given  by  physicians,  having  in  mind 
the  theory  that  strangulation  comes  from  a  spasm  of  muscular 
tissue,  and  that  when  this  spasmodic  action  is  overcome  reduc- 
tion of  the  hernia  can  be  accomplished.  It  is  believed  that  all 
operators  of  large  experience  will  bear  out  the  statement  that 
no  such  condition  is  found  to  exist  at  the  time  of  operation. 
Perhaps  no  drug  has  been  the  cause  oi  more  deaths  in  strangu- 
lated hernia  than  opium  and  its  products.  The  hypodermic 
injection  of  morphine,  which  has  been  such  a  blessed  relief  to 
the  patient,  has  misled  JDoth  him  and  the  attendant  into  the 
belief  that  the  conditions  were  improved,  while  in  reality  the 
pathological  changes  which  take  place  in  strangulated  intestine 
have  been  rapidly  advancing,  and  when  the  physician  has  dis- 
covered his  error  it  is  too  late  to  save  the  patient.  This  means 
of  relief  to  the  suffering  may  and  should  be  given  while 
preparations  for  a  more  rational  and  radical  form  of  relief 
are  being  made. 

427 


428  ABDOMINAL  HERNIA. 

The  use  of  coffee  or  cathartics  is  thoroughly  irrational, 
although  they  have,  in  some  instances,  hastened  relief  by  caus- 
ing violent  peristaltic  action  of  the  bowel  and  thereby  aiding 
in  its  withdrawal  from  the  point  of  constriction.  This,  no 
doubt,  is  the  only  action  which  strong  decoctions  of  coffee  have. 
The  coffee  has  one  advantage  over  cathartics  in  that  it  is  a 
powerful  stimulant  and  delays  the  period  of  collapse.  The 
cathartic  is  sure  to  leave  the  patient  in  much  worse  condition 
than  before  it  was  taken,  and  only  in  the  rarest  instances  does 
it  accomplish  the  desired  result. 

Safety  is  on  the  side  of  limiting  medication  tO'  the  hypo- 
dermic use  of  morphine  (preferably  combined  with  atropine), 
and  the  application  of  cold  to  the  tumor,  to  afford  the  patient 
partial  relief  while  preparations  for  the  operation  are  being 
made;  these  should  be  advanced  with  all  possible  haste,  even 
though  the  opiates  have  temporarily  placed  the  patient  in  a 
perfectly  comfortable  condition. 

Taxis. — By  the  word  "  taxis,"  a  very  indefinite  idea  is 
conveyed  to  the  mind  of  the  average  physician  regarding  a 
certain  form  of  manipulation,  which  may  be  more  or  less 
violent,  according  to  the  peculiarities  of  the  manipulator,  and 
the  works  on  surgery,  even  of  the  later  day,  contain  very  little 
precise  information  regarding  its  technique. 

Taxis  comes  midway  between  the  medical  and  the  surgical 
treatment  of  strangulated  hernia,  but  properly  belongs  to  the 
surgical  side,  and  the  operator  should  bear  in  mind  that  it  is 
a  delicate  surgical  procedure  to  attempt  to  reduce  strangulated 
intestine  by  means  of  manipulation.  He  should  realize  the 
fact  that  not  only  is  he  liable  to  fail  to  accomplish  the  desired 
result,  but  he  is  apt  to  add  materially  to  the  risks  which  his 
patient  has  already  incurred.  The  length  of  time  this  method 
should  be  used  can  scarcely  be  stated,  as  one  man  will  do 
more  harm  to  the  parts  than  another. 

There  are  perhaps  few  things  in  surgery  where  more 
actual  skill  is  required  and  can  be  displayed  than  in  the  reduc- 
tion of  strangulated  bowel  by  manipulation,  or  so-called  taxis. 


MEDICAL  TREATMENT:  STRANGULATED.     429 

The  author  has,  for  many  years,  avoided  the  use  of  this  word 
ahiiost  entirely,  and  has  taught  the  reduction  of  hernia  by  what 
he  has  called  traction  and  compression,  which  is  accomplished 
in  the  following  manner : 

Try  at  once  to  assure  your  patient  that  you  are  not  going 
to  add  to  his  torture,  and  confirm  this  in  his  mind  by  handling 
the  tumor  with  the  greatest  gentleness.  By  this  you  will  secure 
his  co-operation  instead  of  unconscious  resistance.  Place  him 
on  a  table  with  the  hips  well  elevated,  instead  of  working  over  a 
soft  and  yielding  bed.  An  ordinary  kitchen  table,  with  the  legs 
at  one  end  elevated  six  or  seven  inches,  answers  every  purpose, 
and  is  obtainable  in  almost  every  house.  When  the  patient  is  in 
position,  first  gently  crowd  the  entire  abdominal  contents  away 
from  lower  abdomen  toward  the  chest,  then  work  the  fingers 
of  one  hand  around  the  neck  of  the  tumor  where  it  issues  from 
the  abdomen,  holding  its  bulk  in  the  palm  of  the  hand  if  pos- 
sible, and,  instead  of  trying  to  push  the  tumor  back  into  the 
abdomen,  try  to  draw  it  farther  down.  Now,  with  the  other 
hand,  grasp  the  canal  with  its  contents  (if  inguinal  hernia) 
gently  but  firmly  between  the  thumb  and  fingers,  and,  while 
making  traction,  and  compression  with  the  hand  that  is  holding 
the  tumor,  manipulate  the  canal  with  a  kneading  motion.  This 
can  be  done  without  adding  to  any  extent  to  the  patient's  pain, 
and  will  succeed  when  more  rude  handling  fails. 

When  you  push  upwards  on  strangulated  hernia,  usually 
you  carry  it  up  over  the  ring  upon  the  abdominal  wall,  and 
accomplish  nothing  more.  In  the  method  suggested,  by  trac- 
tion you  lengthen  out  the  mass  that  is  blockading  the  canal, 
favoring  the  effect  which  you  afterwards  produce  by  compres- 
sion, i.e.,  the  partial  emptying  of  engorged  blood  vessels,  and 
the  displacement  of  gases  and  fluids.  This  is  further  aided  by 
the  action  of  the  fingers  upon  the  canal,  working  the  bowel  free 
at  the  point  of  constriction.  This  work  should  be  done  only 
while  the  patient  is  conscious,  as  his  endurance  of  pain  should 
clearly  indicate  the  amount  of  force  that  it  is  desirable  to  use 
and  beyond  which  it  is  never  safe  to  go. 


430  ABDOMINAL  HERNIA. 

The  amount  of  time  which  should  be  expended  upon  these 
cases  depend  somewhat  upon  their  character.  If  the  hernia 
is  an  extremely  large  one,  and  its  contents  chiefly  omentum, 
considerable  time  may  be  allowed  in  this  manipulation, 
carefully  executed,  without  fear  of  doing  harm  to  the  patient. 
If,  on  the  other  hand,  the  hernia  is  small,  with  acute  symp- 
toms of  strangulated  intestine,  not  more  than  fifteen  minutes 
should  be  expended  in  attempts  at  reduction.  If  it  cannot 
be  reduced  in  this  time,  nothing  but  harm  can  come  of  pro- 
longed handling.  So  far  as  possible,  not  more  than  one  physi- 
cian should  ever  attempt  to  reduce  a  hernia  by  manipulation. 
The  second  one  called  will  do  well  to  take  none  of  the  responsi- 
bility of  handling  the  tumor,  but  should  proceed  at  once  to  the 
operation.  It  should  be  borne  in  mind  that  rude  and  violent 
handling  of  a  strangulated  bow^el  is  far  more  dangerous  than 
an  operation,  even  though  the  latter  be  done  by  a  man  who 
does  not  consider  himself  an  expert. 

External  Applications. — The  literature  on  this  branch  of 
the  subject  is  full  of  delusions  and  snares.  Every  sort  of 
poultice,  hot  and  cold,  that  could  possibly  come  to  the  imagina- 
tion of  man,  has  been  applied  to  strangulated  hernia.  There 
is  only  one  external  application  which  should  be  applied,  and 
only  in  the  earliest  stages  of  the  difficulty,  and  that  is  cold. 
Sulphuric  ether,  allowed  to  drip  slowly  over  the  tumor,  has  been 
very  strongly  recommended,  and  no  doubt  has  scored  some 
successes.  Ethel  chloride  spray  has  also  been  suggested.  The 
only  effect  that  such  an  application  has  is  the  cold  produced  by 
rapid  evaporation,  and  if  it  can  be  obtained  more  conveniently 
in  this  way  than  by  the  application  of  ice,  it  is  all  right.  Per- 
sonally ice  is  preferred.  If  delay  is  necessary  in  preparing  for 
the  operation  in  a  given  case,  two  things  should  always  be 
resorted  to  in  a  pallative  way — the  liypodermic  injection  of 
morphine  to  relieve  pain,  and  the  immediate  application  of  ice 
upon  the  tumor.  Ac^ain  it  must  be  urged  tliat  this  application 
must  be  only  in  the  earlier  stages  before  pathological  changes 
have  taken  place. 


MEDICAL  TREATMENT:  STRANGULATED.     431 

Hernije  of  the  large  type,  containing  large  masses  of 
omentum,  and  where  the  symptoms  are  not  very  acute,  may 
frequently  be  reduced  after  the  application  of  an  ice-bag  for 
twenty-four  hours  or  less.  This  amount  of  delay  must  cer- 
tainly not  be  tolerated  in  cases  where  there  is  extreme  pain  and 
vomiting.  Aspiration  in  order  to  draw  off  the  fluids  of  the 
tumor  and  thereby  aid  in  its  reduction  formerly  had  strong 
advocates.  Not  only  is  there  serious  risk  of  injuring  the 
already  damaged  bowel,  but  it  is  believed  by  the  author  that 
the  fluid  is  both  a  protection  to  the  gut  and  an  aid  in  its 
reduction. 

Anaesthesia  for  the  Reduction  of  Hernia. — The  opinion  of 
the  author  on  this  point  has  been  indicated  by  the  statement 
made  before,  that  taxis  should  be  used  only  on  conscious 
patients.  It  is  believed  that  it  seldom  happens  that  a  judicious 
amount  of  force  is  used  where  the  patient  is  under  the  effects  of 
anaesthetics,  and  that  this  force  applied  to  strangulated  intestine 
is  more  dangerous  than  operation  for  its  relief.  An  anaes- 
thetic should  seldom  be  given  until  all  preparations  for  the 
operation  have  been  completed.  This  rule  does  not  hold  good 
with  Infants,  in  whom  reduction  is  so  frequently  accomplished. 

In  some  instances,  where  the  patient  Is  very  much  alarmed 
regarding  the  operative  part  of  the  work.  It  Is  a  comfort  to 
him  to  be  assured  that  an  attempt  will  be  made  to  reduce  the 
hernia  after  the  anaesthetic  has  been  given,  and  that  only  In 
case  this  fails  will  the  operation  be  done :  manipulation  should 
be  even  more  gently  executed  than  were  the  attempts  at  reduc- 
tion while  the  patient  was  conscious. 


CHAPTER  XXVI. 

SURGICAL  TREATMENT   OF   STRANGULATED 
INGUINAL  HERNIA. 

As  previously  intimated,  the  treatment  of  strangulated 
hernia,  from  first  to  last,  belongs  strictl}^  within  the  domain 
of  surgery.  The  cases  are,  however,  usually  first  seen  by  the 
practitioner  of  medicine,  who,  perhaps,  ordinarily  does  nothing 
but  minor  surgery  and  who  has  been  taught  tO'  look  upon  an 
operation  for  this  affliction  as  belonging  to  the  major  opera- 
tions. Unfortunately,  also,  a  surgeon  may  not  be  within 
easy  call  and  hence  the  liability  to  delay  means  death  to  the 
patient.  In  an  emergency  of  this  character  it  is  far  better  that 
the  practitioner  subject  his  patient  to  the  risk  attendant  upon 
an  unskilful  operation  rather  than  to  those  involved  in  delay. 
The  life-saving  element  in  this  operation  is  not  difficult  to  carry 
out  if  done  early  in  the  case  before  complications,  due  to  dis- 
ease, have  set  in.  It  is  purely  a  mechanical  problem  and 
rec[uires  no  such  anatomical  knowledge  as  is  usually  supposed. 
An  unyielding  band  of  some  sort  surrounds  the  intestine  and 
must  be  cut. 

There  are  two  operations  that  every  physician  should 
be  prepared  to  perform  at  the  very  shortest  notice;  viz., 
Tracheotomy  and  Herniotomy.  The  difficulties  of  both  have 
been  exaggerated  by  the  too  careful  anatomical  consideration 
of  the  parts.  I  do  not  mean  by  this  to  discourage  minute  and 
exact  anatomical  knowledge;  but  it  is  not  possible  that 
ever\^  physician  should  remain  throughout  life  a  perfect 
anatomist,  nor  should  he  be  discouraged  from  executing  these 
life-saving  measures  because  he  has  forgotten  the  number  and 
distribution  of  the  vessels  and  nerves  of  the  parts. 

The  preparations  and  instruments  may,  if  necessary,  be  of 
the  simplest  character.     The  author  has  operated  with  nothing 

4.32 


SURGICAL  TREATMENT:  STRANGULATED.     433 

but  a  knife,  clamp,  scissors,  and  needle  from  a  borrowed  pocket 
case,  and  silk  from  the  work-basket  of  the  patient's  wife.  It  is 
beyond  c[uestion  that  the  patient's  life  was  saved  in  this  instance 
by  the  immediate  release  of  the  imprisoned  gut.  Where  time 
allows,  it  is  uncjuestionably  better  that  every  preparation  be 
made  that  usually  attends  any  other  abdominal  surgery.  In 
any  case  the  parts  must  be  thoroughly  cleaned,  the  water, 
instruments,  and  towels  used  about  the  wound  boiled,  and  the 
greatest  source  of  danger,  the  operator's  hands,  must  be  made 
aseptic  by  much  scrubbing,  closely  trimmed  nails,  and  such  anti- 
septics as  may  be  at  command. 

If  fecal  vomiting  has  already  occurred,  it  is  advisable  to 
wash  out  the  stomach  before  giving  an  anaesthetic.  The  pres- 
ence of  this  poisonous  matter  in  the  stomach  certainly  leads  to 
toxemia  and  adds  to  existing  shock  and  prostration.  Further- 
more, vomiting,  which  is  quite  sure  to  occur  during  anaesthesia, 
may  result  in  carrying  this  matter  into  the  lungs  by  inspiration, 
thus  causing  pneumonia.  The  question  as  to  the  advisability 
of  giving  a  general  anaesthetic,  or  resorting  to  local  anaesthesia, 
must  be  seriously  considered.  If  the  case  has  already  existed 
for  some  time,  with  shock  and  fecal  vomiting  present,  sensation 
is  considerably  blunted,  and  by  the  aid  of  local  anaesthesia  the 
operation  may  be  done  without  unbearable  pain.  The  local 
anaesthetic  recommended  is  cocaine  by  the  Schleick  method, 
always  being  careful  not  to  exceed  the  physiological  dose  of 
the  drug. 

The  Incision. — If  the  hernia  is  large,  this  should  be  a  little 
longer  than  that  made  in  the  operation  for  the  radical  cure,  but 
on  the  same  lines.  It  should  extend  from  above  the  internal 
ring  to  a  point  over  the  upper  part  of  the  pubic  bone,  following 
the  direction  of  the  cord  in  the  male,  and  opening  up  the  entire 
canal. 

In  making  this  incision  the  superficial  pubic  vessels  will  be 
cut  at  the  lower  angle  of  the  wound  and  the  superficial  epigas- 
tric vessels  at  its  upper  angle.  Both  are  between  the  skin  and 
the  external  oblique  muscle,   and,   while  they  will  probably 

28 


434  ABDOMINAL  HERNIA. 

require  clamping,  are  unimportant.  If  they  are  large  and  bleed 
freely  it  is  better  to  tie  them  at  once  with  small-sized  catgut; 
if  small,  merely  allow  the  clamps  to  remain  on  while  other  work 
is  being  done ;  they  will  then  frequently  be  found  permanently 
closed.  It  is  essential,  however,  that  no  oozing  points  remain 
when  the  parts  are  closed. 

The  opening  of  the  canal  should  now  be  accomplished  by 
splitting  the  aponeurosis  of  the  external  oblique  from  a  little 
above  the  internal  ring  to  the  external  ring.  Where  the  external 
ring  is  sufficiently  free  to  allow  of  it,  this  is  best  done  by  slipping 
in  a  grooved  director  and  cutting  upon  it,  but  in  strangu- 
lated hernia  it  is  seldom  possible  owing  to  the  constricting 
bands  about  the  ring.  In  this  case  a  small  opening  may  be 
made  in  the  aponeurosis  directly  over  the  internal  ring  and  the 
cutting  done  by  knife  or  blunt  pointed  scissors,  following  down 
in  the  direction  of  its  fibres  to  the  external  ring.  In  many 
instances  when  the  canal  has  been  freely  opened  and  the  con- 
stricting bands  at  the  external  ring  cut,  the  cause  of  the  strangu- 
lation will  have  been  removed  and  the  hernia  can  be  reduced; 
it  is  highly  important,  however,  that  this  should  not  be  done 
until  the  contents  of  the  sac  have  been  carefully  examined.  On 
the  contrary,  it  may  be  that  the  constriction  is  in  the  neck  of  the 
sac,  or  by  transverse  bands  within  the  sac  itself,  or  a  loop  of 
bowel  may  be  strangulated  through  a  hole  in  the  omentum.  In 
any  case  the  sac  must  be  opened.  The  sac,  having  now  been 
well  exposed,  should  be  carefully  stripped  loose  from  its 
adhesions  and  lifted,  with  the  cord  still  attached,  out  of  the 
canal. 

This  loosening  of  the  sac  is  done  by  gently  pressing  the 
fingers  around  it  in  every  direction,  and  it  is  easier  while 
the  sac  is  full  than  when  it  is  emptied.  Even  when  very 
large  and  in  the  scrotum,  it  may,  in  this  way,  be  delivered 
through  the  high  incision.  The  cord  may  sometimes  be  easily 
separated  before  opening  the  sac,  but  unless  the  fatal  band  of 
constriction  has  already  been  cut,  veiy  little  time  should  be  lost 
in  this  work,  but  proceed  at  once  to  the  opening  of  the  sac. 


SURGICAL  TREATMENT:  STRANGULATED.      435 

The  discussion  as  to  whether  or  not  the  sac  should  be  opened 
belongs  to  a  past  age;  it  should  always  be  opened. 

Much  care  must  be  exercised  at  this  stage  of  the  opera- 
tion, as  it  not  uncommonly  happens  that  the  bowel  has  become 
adherent  to  the  sac,  and  to  cut  carelessly  one  would  be  quite 
certain  to  open  into  the  intestine.  In  almost  every  instance  of 
strangulated  bowel  there  is  rapid  effusion  of  fluid,  and  the 
opening  into  the  sac  should  be  at  a  point  where  this  is  felt  to 
be  present.  Usually  this  will  be  at  or  near  the  bottom  of  the 
sac.  This  fluid  may  be  a  clear,  colorless  serum,  or  it  may  be 
of  dark  coffee  color  and  of  the  most  offensive  odor.  If  of  the 
latter  variety  it  is  full  of  septic  matter  and  indicates  a  very 
grave  state  of  affairs. 

The  sac  having  been  freely  opened,  the  constriction  should 
be  searched  for  and  cut.  The  bowel  should  now  be  drawn 
down  so  that  the  part  which  has  been  subjected  to  the  greatest 
pressure  can  be  inspected.  This  usually  is  the  point  of  greatest 
danger.  The  bowel  may  present  any  degree  of  injury,  from 
a  mere  congestion  of  its  surface  vessels  to  gangrene  and 
perforation,  according  to  the  length  of  time  strangulation  has 
existed,  the  tightness  of  the  stricture,  and  the  amount  of  rough 
handling  it  has  been  subjected  to  by  those  trying  to  reduce  it. 
It  is  not  uncommon  to  find  it  a  dark  claret  color,  and  if  there 
are  no  gangrenous  spots,  it  may  recover  fully  from  this  degree 
of  injury  under  proper  treatment.  When  the  bowel  has  been 
drawn  well  down  and  all  constriction  removed,  it  is  believed 
that  there  is  nothing  so  beneficial  as  the  application  of  towels 
wrung  out  of  hot  sterilized  water.  It  is  perfectly  justifiable 
to  spend  half  an  hour  or  more,  if  necessary,  in  restoring  the 
bowel  in  this  way.  If  a  change  in  color  to  a  lighter  shade  is 
effected,  it  may  be  assumed  that  the  bowel  will  live.  If,  how- 
ever, there  are  spots  of  a  dull,  ashen-gray  color,  which  have 
lost  the  lustre  natural  to  the  bowel,  it  may  be  known  that  these 
are  liable  to  perforation  if  returned  to  the  abdomen.  If  not  too 
large,  they  may  be  folded  in  and  the  healthy  edges  of  the  bowel 
united  by  Lembert  sutures  of  fine  silk. 


436  ABDOMINAL  HERNIA. 

If  perforation  has  actually  occurred,  and  the  bowel  is  so 
far  damaged  as  to  preclude  its  repair  by  the  turning  in  of  its 
torn  edges,  then  resection,  or  the  formation  of  an  artificial  anus, 
should  be  considered.  In  this  desperate  condition,  unless  the 
operator  is  quite  familiar  with  intestinal  surgery,  it  will  be  a 
life-saving  measure  to  anchor  the  bowel  in  the  wound  by  a  few 
stitches,  covering  it  by  moist,  warm  dressings,  to  be  frecjuently 
changed.  Should  the  patient  survive,  resection  may  be  done  as 
a  secondar}^  operation  under  more  favorable  conditions.  Gib- 
son in  a  valuable  article  on  "  Gangrenous  Hernia  "  {Annals  of 
Surgery,  vol.  xxxii,  p.  486)  gives  the  mortality  in  these  cases, 
in  the  three  most  common  forms  of  hernia,  as  follows: 
Inguinal,  26  per  cent. ;  femoral,  37  per  cent. ;  umbilical,  67 
per  cent.  If  the  operator  has  at  hand  the  ]\Iurphy  button, 
primary  resection  may  be  quickly  done,  but  even  the  handling 
of  the  bowel  necessary  for  that  method  adds  to  the  profound 
shock  from  which  the  patient  usually  suffers  in  the  extreme 
cases  under  consideration. 

Strangulated  omentum  found  within  the  sac  should  always 
be  removed,  as  returning  it  to  the  abdomen  adds  materially  to 
the  patient's  danger.  Omentum  which  has  been  under  press- 
ure and  is  inflamed  may  slough  if  returned  to  the  abdominal 
cavity.  Its  ligation  should  be  carefully  done,  as  accidents 
from  secondary  hemorrhages  have  occurred,  even  in  the 
hands  of  noted  operators.  It  is  well  understood  now,  however, 
that  accidents  come  from  ligating  large  masses  of  omentum 
together  and  the  subsequent  slipping  of  the  ligature.  The 
omentum  should  be  spread  out  thin  and  every  vessel  that  can 
be  seen  tied,  with  as  little  fat  as  possible  included.  The  fat 
should  then  be  tied  separately.  This  subject  has  been  fully 
dealt  with  under  the  surgical  cure  of  hernia. 

An  ovary  or  testicle  in  the  canal  must  be  treated  accord- 
ing to  its  condition.  If  unhealthy,  it  is  very  easy  to  remove  it; 
if  normal,  it  should  be  restored  to  its  natural  position.  A 
normal  testicle  with  a  cord  so  short  that  it  will  not  reach  the 
scrotum  should  be  treated  in  the  manner  described  under  the 


SURGICAL  TREATMENT:  STRANGULATED.     437 

heading-,  "  Complications  in  the  Operative  Cure  of  Inguinal 
Hernia."  The  reader  is  also  referred  to  this  section  for  details 
regarding  the  closure  of  the  wound,  as  it  should,  with  rare 
exceptions,  be  so  closed  as  to  effect  a  permanent  cure  of  the 
trouble  which  has  proven  such  a  serious  menace  to  the  life  of 
the  patient. 

The  after-treatment  of  the  case  should  be  conducted  upon 
general  principles  to  meet  conditions  present.  Shock  should 
be  as  promptly  overcome  as  possible  by  hypodermic  and  rectal 
stimulation,  and  by  surrounding  the  body  with  artificial  heat. 
One  of  our  most  valuable  means  of  combating  shock  is  trans- 
fusion, the  introduction  of  normal  saline  solution  into  the 
circulation.  A  strong  decoction  of  coffee  for  rectal  enema  has 
proven  efficacious.  It  is  not  deemed  good  practice  to  give 
cathartics  early  after  strangulated  hernia,  especially  if  the 
bowel  has  been  badly  compressed.  Pressure  paralysis  is  liable 
to  result,  even  though  the  coats  of  the  gut  have  suffered 
little  visible  damage.  It  is  better  to  give  the  bowel  complete 
rest  for  a  few  days  unless  there  are  other  symptoms  contra- 
indicating  this  course.  It  is  also  better  to  empty  the  lower 
bowel  thoroughly  by  enema  before  giving  laxatives.  It  must 
be  remembered  that  perforation  has  occurred  as  late  as  the 
tenth  day  after  doubtful  bowel  has  been  returned  to  the 
abdomen.  Fluid  food  should  therefore  be  continued  for  this 
length  of  time  in  suspicious  cases. 

Hemorrhage  from  the  bowel,  of  greater  or  lesser  degree, 
may  occur  after  the  return  of  the  damaged  gut,  coming  on  from 
the  first  to  the  third  day  after  the  operation.  Children  are 
especially  liable  to  this,  and  it  has  been  seen  where  strangula- 
tion existed  for  only  a  few  hours,  and  where  the  hernia  had 
been  carefully  reduced  without  operation.  In  no  instance  has 
a  fatal  or  very  serious  result  been  seen  by  the  author.  If  this 
hemorrhage  is  accompanied  by  persistent  diarrhoea  it  becomes 
a  more  serious  matter,  and  repeated  small  doses  of  opium  are 
recommended.  The  Subgallate  of  Bismuth,  in  doses  of  from 
5  to  lo  grains  every  hour,  has,  in  the  experience  of  the  author, 


438  •  ABDOMINAL  HERNIA. 

acted  very  nicely  and  saved  the  giving  of  opium,  which  is 
usually  contra-indicated  by  the  condition  of  the  patient.  A  few 
loose  movements  produced  by  cathartics,  unwisely  given  before 
the  operation,  must  not  be  mistaken  for  the  condition  here 
named. 

In  almost  every  instance  of  strangulated  hernia  evidence 
is  found  of  localized  peritonitis,  which,  in  a  few  cases,  becomes 
general  after  the  operation  and  must  be  treated  accordingly. 
First  among-  remedies  is  believed  to  be  the  ice  coil,  but  this  must 
not  be  applied  while  the  patient  is  still  in  a  condition  of  shock 
from  the  effects  of  strangulation.  All  of  these  complications 
result  from  delay,  and  will  not  be  seen  where  prompt  operative 
relief  has  been  afforded.  The  operation  itself  is  not  one  of 
danger. 


CHAPTER  XXVII. 

STRANGULATED  FEMORAL  HERNIA. 

Symptoms. — The  symptoms  of  strangulated  femoral 
hernia  do  not  differ  materially  from  those  attending  strangula- 
tion at  other  points,  except  that  the  attack  is  likely  to  be  more 
violent,  the  prostration  (shock)  is  more  profound,  and  dis- 
astrous results  more  quickly  supervene  if  relief  is  not  promptly 
afforded.  The  reasons  for  this  especial  violence  in  femoral 
hernia  have  been  entered  into  in  the  anatomical  considerations 
of  the  subject  and  need  not  be  repeated  here;  but  the  urgent 
necessity  for  the  earliest  action  possible  cannot  too  often  be 
impressed  upon  the  physician,  nor  must  he  allow  the  temporary 
relief  afforded  by  opiates  to  mislead  or  delay  him  for  a 
moment.  From  the  beginning  of  an  attack  to  an  early  fatal 
issue  the  destructive  pathological  changes  advance  rapidly. 

When  the  intestine  forms  the  contents  of  the  hernia  there 
may  be  some  premonitory  abdominal  discomfort,  but  it  is  more 
common  for  the  pains  to  become  severe  at  once,  followed 
rapidly  by  all  of  the  grave  symptoms  of  acute  intestinal  obstruc- 
tion; general  abdominal  pain,  vomiting,  prostration,  and  col- 
lapse. Old  and  feeble  people  may  die  from  this  collapse  or 
shock  within  a  very  brief  period  of  time,  and  before  patho- 
logical changes  have  taken  place  to  a  sufficient  degree  to  cause 
death. 

Absence  of  local  pain  has  undoubtedly  misled  the  physician 
in  very  many  instances,  and  hastened  a  fatal  issue.  It  is  not 
uncommon  that  the  abdominal  distress  is  so  great  that  the 
patient's  attention  is  not  called  to  the  site  of  the  hernia  at  all ; 
he  may  not  even  know  that  hernia  exists.  Contrary  tO'  experi- 
ence in  inguinal  hernia,  the  author  has  seen  several  cases  of 
femoral  where  it  was  quite  evident  that  strangulation  had  taken 
place  with  the  very  first  protrusion.     Where  decided  abdominal 

439 


440  ABDOMINAL  HERNIA. 

disturbances  exist  all  locations  where  hernia  commonly  occurs 
should  be  carefully  examined  and  any  abnormal  condition 
found  should  be  looked  upon  with  decided  suspicion.  In  the 
femoral  region,  especially,  a  small  kernel  no  larger  than  the 
end  of  the  little  finger,  the  existence  of  which  is  wholly 
unknown  to  the  patient,  may  be  an  imprisoned  knuckle  of 
bowel  which  will  certainly  result  in  death  if  not  recognized 
and  relieved. 

Where  omentum  only  is  strangulated,  the  symptoms  may 
be  of  the  mildest  type,  amounting  to  discomfort  rather  than 
pain  in  the  abdomen,  with  a  burning,  or  dragging  sensation, 
the  latter  usually  in  the  umbilical  region.  While  these  cases 
demand  early  surgical  attention,  there  is  not  the  urgent  need 
for  haste  as  when  the  bowel  is  imprisoned.  In  fact,  this  acci- 
dent occurs  many  times  without  the  true  condition  being 
realized  by  either  the  physician  or  the  patient.  When  the  tem- 
porary congestion' of  the  strangulated  omentum  subsides  or  its 
fat  is  entirely  destroyed  by  cutting  off  its  circulation,  it  leaves 
the  patient  with  a  permanently  irreducible  hernia.  These 
hernise  are  very  likely  to  increase  in  size,  they  are  more  dan- 
gerous to  the  patient  than  the  reducible  type,  and  should 
therefore  be  cured  by  operative  means  at  the  earliest  conveni- 
ent moment. 

Reduction  by  Taxis. — All  that  has  been  said  regarding 
the  reduction  of  inguinal  hernia  by  so-called  "  Taxis,"  or 
manipulation,  applies  here,  with  two  exceptions:  (i)  The 
length  of  time  that  taxis  is  used,  and  the  degree  of  force 
employed,  should  be  decidedly  modified.  The  tightness  and 
knife-edge  character  of  the  constriction  in  strangulated  femoral 
hernia  make  the  chances  of  damaging  the  bowel  by  handling 
much  greater  and  the  probabilities  of  success  less.  Therefore, 
the  greatest  caution  and  gentleness  in  handling  should  be  exer- 
cised. (2)  The  direction  of  pressure  should  be  downward 
and  toward  the  centre  of  the  thigh.  Any  pressure  upward 
only  draws  the  intestine  up  over  Poupart's  ligament  and  does 
not  aid  in  the  least  in  its  reduction. 


STRANGULATED  FEMORAL  HERNIA.  441 

Medical  Treatment. — Properly  there  is  no  medical  treat- 
ment for  strangulated  femoral  hernia.  If  the  hernia  is  large 
and  the  symptoms  not  very  acute,  indicating  that  the  mass  may 
contain  considerable  omentum,  the  ice  bag  should  be  applied 
while  preparing  for  operation.  This  is  not  advisable  if  the 
attack  has  been  of  long  enough  duration  to  allow  of  destructive 
pathological  changes,  and  if  shock  is  present.  It  will  not  be  of 
much  service  if  the  hernia  is  small  and  its  contents  exclusively 
intestine.  Morphine  combined  with  atropine  should  be  used 
for  the  immediate  relief  of  the  patient  while  preparations  are 
being  made  to  operate,  but  with  no  other  idea  than  that  of 
temporary  comfort.  Do  not  be  delayed  one  moment  in  prompt 
action,  by  the  great  relief  that  it  affords. 

OPERATION    FOR  STRANGULATED   FEMORAL    HERNIA. 

All  preparations  for  the  operation  for  strangulated 
femoral  hernia  should  be  attended  by  the  same  strict  regard  for 
asepsis  that  is  carried  out  in  every  important  surgical  pro- 
cedure. The  incision  is  the  same  as  in  the  operation  for  the 
cure  of  femoral  hernia.  The  sac  should  be  loosened  from  its 
bed  and  brought  out  through  the  skin  incision  and  its  neck  fully 
freed  in  the  canal  before  opening.  The  constriction  in  femoral 
hernia  is  almost  invariably  beneath  Poupart's  ligament,  and 
may  be  either  in  the  neck  of  the  sac  itself  or  by  its  surrounding 
ligamentous  structures.  After  raising  the  sac  and  its  contents 
out  of  its  bed,  and  the  neck  has  been  well  freed,  it  is  then  care- 
fully opened.  It  may  be  split  up  to  and  through  its  neck  with 
little  danger  of  injury  to  the  bowel.  This  almost  uniformly 
divides  the  constricting  band.  In  cutting  the  stricture  in 
strangulated  femoral  hernia,  keep  constantly  in  view  the  fact 
that  the  parts  are  to  be  so  closed  afterwards  as  to  protect  the 
patient  against  recurrence  of  the  trouble.  This  cannot  be  done 
if  Poupart's  ligament  is  divided. 

On  opening  the  sac  it  is  very  common  to  find  it  filled  with 
a  coffee-colored  fluid  which  is  a  product  of  strangulation  and 
does    not   necessarily    indicate   that    the   case    is   particularly 


442  ABDOMINAL  HERNIA. 

serious.  If  this  fluid  has  a  strong  fecal  odor,  every  precaution 
should  be  used  to  protect  the  wound,  as  it  is  quite  sure  to  con- 
tain septic  matter.  The  adhesions  ordinarily  found  between 
bowel  and  sac  are  of  recent  origin  and  are  usually  easily 
separated.  If,  however,  they  are  so  firm  as  to  endanger  the 
tearing  of  the  intestine,  it  is  better  surgery  to  cut  out  this 
adherent  patch  of  sac  and  leave  it  attached  to  the  bowel.  No 
harm  will  result  from  this  method  of  procedure. 

All  omentum  that  has  been  under  constriction  should  be 
ligated  and  cut  away  in  the  manner  described  in  the  chapter 
on  inguinal  hernia.  Intestine  that  has  been  constricted  must 
be  carefully  examined  for  damaged  places  and  especially  must 
it  be  drawn  down  until  normal  bowel  is  seen  on  both  ends  of 
the  loop  in  order  to  inspect  the  line  that  has  formed  at  the 
point  of  greatest  pressure. 

Hot  towels,  as  already  suggested  (see  Inguinal  Hernia), 
will  obviate  the  necessity  for  resection  in  many  instances.  The 
completion  of  the  operation  should  be  in  accordance  with  the 
suggestions  for  operative  cure.  It  seldom  happens  that  the 
case  is  so  extreme  that  the  proper  closure  of  the  parts  to  secure 
a  permanent  cure  cannot  be  carried  out  without  additional  risk 
to  the  patient. 


CHAPTER  XXVIII. 

STRANGULATED  UMBILICAL  HERNIA. 

In  no  cases  of  strangulated  hernia  is  the  prognosis  more 
grave  than  in  those  occurring  at  the  umbihcus.  This  is  for 
the  two-fold  reason  that  strangulation  usually  occurs  in  herniae 
of  enormous  size,  where  adhesions  are  numerous,  and  in  very 
fat  patients  whose  resistance  is  poor.  It  can  seldom  be  reduced 
by  taxis,  as  the  abdominal  wall  is  so  flexible  as  tO'  furnisli  very 
little  resistance,  and,  when  the  hernia  is  pushed  upon,  the  whole 
wall  is  carried  back  and  nothing  is  accomplished.  The  symp- 
toms are  in  every  respect  similar  to  those  of  intestinal  strangu- 
lation elsewhere.  The  use  of  the  ice-bag  here  has,  in  the 
author's  experience,  been  attended  with  good  results,  owing, 
doubtless,  to  the  fact  that  in  many  instances  umbilical  hernia 
contains  a  large  amount  of  omentum. 

The  operation  must  be  conducted  on  the  same  general 
principles  which  govern  that  for  other  cases  of  umbilical  hernia. 
Great  caution  is  necessary  in  making  the  initial  incision,  as  dis- 
tended bowel  may  lie  in  such  close  contact  with  the  inner 
surface  of  the  sac  that  the  cutting  of  one  is  pretty  sure  to 
accidentally  open  into  the  other.  Here,  as  in  other  cases  of 
strangulated  hernia,  fluid  is  quite  sure  to  collect  in  some  part 
of  the  sac,  and  usually  it  can  be  safely  opened  by  taking  up  a 
small  piece  of  the  latter  between  anatomical  forceps.  In  many 
cases  the  knuckle  of  bowel  that  is  in  trouble  may  be  inside  of  a 
layer  of  omentum,  and  on  opening  the  sac  it  is  a  great  error  to 
try  to  reduce  the  whole  mass  without  examination.  The  bowel 
that  is  pinched  must  be  found  and  its  condition  carefully  con- 
sidered. That  which  has  been  previously  said  regarding  the 
treatment  of  strangulated  intestine  applies  here  as  well.  In  one 
of  my  own  cases,  on  opening  a  large  sac  a  mass  of  omentum  and 
a  loop  of  intestine  were  found,  both  apparently  normal,  except 

443 


444  ABDOMINAL  HERNIA. 

that  the  former  was  hypertrophied  and  adherent  in  several 
places.  The  intestine  was  easily  reduced  through  a  perfectly 
patent  umbihcal  ring,  whereupon  it  was  discovered  that  the 
strangulation  of  the  bowel  was  through  a  hole  in  the  omentum 
just  within  the  abdominal  wall.  In  another  case  the  bowel  was 
found  incarcerated  under  a  tough  fibrous  band,  the  remains  of 
the  obliterated  umbilical  vessels;  it  was  flexed  upon  itself  at 
such  an  acute  angle  as  to  entirely  close  the  lumen  of  the  bowel. 

Umbilical  sacs  of  large  size  are  much  more  liable  to  have 
connecting  fibrous  bands  running  across  them  in  various  ways 
than  large  sacs  in  other  forms  of  hernia,  and  in  these  bands 
intestine  is  quite  liable  to  become  entangled.  In  these,  as  in  all 
other  large  hernise,  all  parts  of  the  bowel  that  are  reducible 
should  be  returned  to  the  cavity  of  the  abdomen  as  quickly  as 
possible  and  with  the  smallest  amount  of  handling.  Such  parts 
as  cannot  be  immediately  replaced  should  be  covered  with 
moist,  hot,  sterile  towels,  changed  sufficiently  often  to  maintain 
a  temperature  of  about  lOO  degrees. 

The  treatment  of  strangulation  in  the  rarer  forms,  ventral, 
lumbar,  obturator,  and  perineal  hernia,  needs  no  special  con- 
sideration. When  there  is  intestinal  obstruction  and  hernia 
exists  at  any  point,  time  will  usually  be  saved  by  operating 
first  at  the  site  of  this  hernia,  wherever  located,  even  though 
there  are  no  local  symptoms. 


SUMMARY  OF  1,411  PERSONAL  OPERATIONS  FOR 
ABDOMINAL  HERNIA. 

{Tabulated  January,  1902.) 

Males,  757.     Females,  274.     Patients,  1,031. 

Ages  under  10  years  (27  under  5  years;  youngest  5  months) . .   166 
137 


"  10  to 

20 

"  20  " 

30   " 

"   30  " 

40   " 

"  40  " 

50   ' 

"   50  '• 

60   ' 

"   60  " 

70   " 

"   70  " 

80   " 

"  over 

80   " 

221 

198 

140 

93 

47 

27 

2 

103 1 
Under  14  years,  239.     Over  14  years,  792. 

Inguinal  Hernia:    Right,  713.     Left,  524.     (Double,  253)....  1237 
(1205   were   operated   upon  by   Bassini   method) 

Femoral  Hernia:    Right,   75.     Left,  44.     (Double,   12) 119 

(119   operated   upon   by   De   Garmo    method) 

Umbilical   Hernia    35 

Ventral   Hernia    20 

1411 

5  had  Inguinal  Hernia  on  one  side  and  Femoral  on  the  other. 

6  "     Double  Inguinal  and  Femoral. 

2     "     Inguinal  and  Femoral  on  same  side. 

I     "    Double  Inguinal  and  Umbilical. 

I     "     Inguinal  and  Umbilical. 

I     "     Femoral  and  Umbilical. 

Triple  operations  were  done  upon  the  same  patient  in  7  instances. 

The  Bladder  was  recognized  but  not  opened 17 

The  Bladder  not  recognized  and  opened  for  sac i 

(All    in    inguinal    hernia) 

Ovary  in  canal   5 

(Youngest  In  girl  of  7  years) 

Fallopian  tube  adherent  outside  Umbilical  ring i 

The  Appendix  was  found  involved  and  removed  through  inguinal 

incision    19 

Retained  Testes:    Right,  39.     Left,  2)2>-     (Double,  8) 72 

445 


446  SUMMARY. 

Varicocele  sufficient  to  require  operation 32 

(Operation  through  inguinal  incision  in  31) 

Hydrocele 31 

Hernia  irreducible  208 

Omentum  removed   230 

Hernia  strangulated  (Inguinal  21,  Femoral  16,  Umbilical  8)..     45 
Recurrences,  19.     Reoperated  upon,  9 lO 

Mortality. 
43   Operations   for   Strangulated   Hernia :    deaths 9 

1257  "  "       Cure  of  Hernia:   deaths 8 

The  operations  for  cure  of  hernia  were  not  all  operations  of  choice. 
While  some  were  considered  "  extra  hazardous,"  it  was  believed  safer 
to  operate  than  to  leave  the  patient  to  the  risks  of  his  condition.     My — 

1st  death  (Case  No.  429)  in  the  latter  class  was  a  man  of  75 
years,  completely  disabled  by  the  size  of  his  hernia. 
He  stood  the  operation  perfectly,  and  his  condition  was 
good  until  on  the  third  night,  when  he  got  out  of  bed 
and  went  to  the  toilet.  He  was  missed  from  bed  on 
return  to  ward  of  the  night  nurse  and  was  found  in  the 
toilet  room  in  a  state  of  collapse,  from  which  he  never 
recovered. 

2d  death  (Case  No.  467).  Boy  8  years  old.  Syphilitic  menin- 
gitis 4  days  after  operation.  Autopsy  by  Professor 
Brooks,  Pathologist  of  Post-Graduate  Hospital,  showed 
wound  and  abdominal  cavity  in  normal  condition.  One 
brother  of  this  boy  had  died  of  meningitis  after  a  four 
hours'  illness,  and  another  brother  has  partial  paralysis. 
These  facts  were  not  known  to  author  before  operating. 

3d  death    (Case  No.  583).     Man  48  years  old.     On  7th  day  Sepsis. 

4th  death  (Case  No.  628).  Man  49  years  old,  very  fat.  On  6th 
day  Volvulus,  following  operation  for  sigmoid  hernia. 

5th  death  (Case  No.  731).  Man  55  years.  Left  Complete  In- 
guinal Hernia,  nth  day  Pulmonary  Embolism  follow- 
ing thrombus  of  left  femoral  vein. 

6th  death  (Case  No.  965).  Man  42,  enormously  fat.  Hyper- 
trophied  mesentery.     Inoperable  case.     Shock. 

7th  death  (Case  No.  1280).  Man  56.  Weight  300  lbs.  Very 
large  right  Scrotal  hernia.  Infection  through  drainage 
tube  in  scrotum.     Sepsis  on  5th  day. 

8th  death  (Case  No  1.364).  Man  43.  Double  inguinal  hernia 
of  small  size.  No  unfavorable  symptoms.  Death  on 
3rd  day.     Apoplexy  or  pulmonary  embolism. 


INDEX 

A 

PAGE 

Abnormalities  of  descent  of  testicle 36 

Abscess  differentiated  from,  femoral  hernia 316 

inguinal  hernia 107,  1 10 

Accidents  of  hernia  operation 410 

Acquired  hernia 17 

definition 17 

inguinal 56 

time  of  appearance 18 

Adhesions  of  contents  to  sac  in  inguinal  hernia  as  complication,  to 

operating 261 

to  truss  wearing 182 

Age,  as  contra-indication  to  hernia  operation 410 

as  predisposing  cause  of  hernia 45 

for  applying  truss 193 

Albert,  Professor 410 

Amputation  of  omentum 261 

Ansesthesia  for  reduction  of  strangulated  hernia 431 

Anatomical  defects  as  predisposing  cause  of  hernia 46 

Anatomy  of,  femoral  hernia 298 

inguinal  hernia 20 

umbilical  hernia 345 

Andrews,  Dr.  Edward  Wyllys 227 

Andrews,  Dr.  Frank  T 256 

Appendix,  complicating  femoral  hernia 309 

inguinal  hernia 256 

removal  through  inguinal  hernia  incision 258 

Ascites  as  complication  of  truss  fitting 175 

as  direct  cause  of  hernia 53 

Author's  operation  for  femoral  hernia 445 

inguinal  hernia 218 

umbilical  hernia 375 

powder  for  truss  wearers 202 

summary  of  his  operations  for  abdominal  hernia 445 

B 

Baldwin,  Dr.  J.  F 286 

Bassini  operation 214 

Halsted  operation 228 

modified  by  author 218 

Beck,  Dr.  Carl on 7 

Bladder  hernia 19,  227,  279,  283 

before  operation 285 

frequency  of 284 

indications  at  operation 286 

repair  of  accidental  wounds .  .  .    290 

Blake,  Dr.  Joseph 376 

operation  for  umbilical  hernia 376 

Bloodgood,  Dr ; 228,  237 

Body  of  hernia ig 

Boise,  Eugene 411 

447 


448  INDEX. 

PAGE 

Borchardt 398 

Braun's  space 398 

Brodel  Max 228 

Bubonocele  rara 63 

Bull,  Dr.  Wm.  T 235 

C 

Caecal  hernia 19,  63,  277,  279 

closure  of  sac  in 281 

closure  of  wound  in 283 

differentiated  from  other  inguinal  hernia 98 

Canal  of  Nuck 42 

Care  of  skin  under  truss 201 

Causes  of,  difficulty  in  operating  direct  hernia 227 

femoral  hernia 304 

inguinal  hernia 44 

direct 50 

predisposing 44 

strangulated  inguinal  hernia 413 

traumatic  ventral  hernia 386 

umbilical  hernia 345 

ventral  hernia 383 

Cavity  of  tunica  vaginalis 39 

Chase,  Dr.  Heber 135 

truss  for  femoral  hernia 326 

inguinal  hernia 129,  135 

Children  with  strangulated  ingtiinal  hernia 426 

Classification  of  trusses 118 

Closure,  of  sac  in  caecal  hernia 281 

in  direct  hernia 238 

in  femoral  hernia 33 5 

in  sigmoid  hernia 281 

wound  in  caecal  hernia 283 

in  femoral  hernia 338 

in  inguinal  hernia 223 

in  sigmoid  hernia 283 

points  of  tunica  vaginalis 39 

Coley,  Dr.  Wm.  B 36,  225,  235 

Combination  of  hernias 18 

Common  sense  truss  for  femoral  hernia 326 

Complete  hernia .•  •  •  55 

Complications  and  their  treatment  in  operation  for  inguinal  hernia.  .  239 

to  truss  fitting ^73 

ComDression  and  traction  in  reducing  hernia 429 

Condition  of  umbilical  hernia 349 

Congenital  hernia S6 

definition ^^ 

female  inguinal 4^ 

male  inguinal 4° 

differentiated  from  acquired  inguinal  hernia 92 

time  of  appearance ■ ^° 

umbilical  hernia 3°^ 

diagnosis  and  treatment 3°^ 

Conjoined  tendon ^ ^5 

Constipation  as  direct  cause  of  hernia 5° 

Constituents  of  hernia ^°'  ^9 

Construction  of  trusses ^'^^ 


INDEX.  449 

PAGE 

Contents  of  hernia 19,  20 

femoral  hernia 309,  333 

inguinal  hernia 79 

umbilical  hernia 345,  349 

Continuous  truss  wearing 202 

Contra-indications  to  surgical  cure  of  abdominal  hernia 409 

Cooper,  Sir  Astley 44 

Cough  as  direct  cause  of  hernia 51 

Coverings  of  inguinal  hernia. 77 

umbilical  hernia 348 

Cremasteric  fascia 42 

muscle 216 

Cross  body  truss : 129,  169 

Crural  arch 23 

Crying  in  children  as  direct  cause  of  hernia 53 

Curative  treatment  of  inguinal  hernia 113 

Andrew's  operation  for 227 

author's  operation  for 218 

Bassini's  operation  for 216 

Curtis,  Dr.  B.  Farquhar 284,  291 

Cysts  as  complication  to  truss  fitting 173 

differentiated  from  inguinal  hernia no 

of  tunica  vaginalis 40 

D 

Dangers  of  closure  of  sac  in  direct  hernia 238 

femoral  hernia 297,  306 

Dawbarn,  Robert  H.  M.,  M.D 246 

Deep  epigastric  vessels 27,29 

Definition  of  hernia 17 

acquired  hernia 17 

congenital  hernia 17,  18 

femoral  hernia 17 

inguinal  hernia 17 

umbilical  hernia 17,  344 

ventral  hernia 18,  383 

De  Garmo-Hood  truss 196 

Delayed  testicle 37 

as  complication  of  inguinal  hernia 176 

complication  of  inguinal  hernia  operation 239 

predisposing  cause  of  inguinal  hernia 46 

causes  for 38 

differentiated  from  inguinal  hernia 107,  109 

function  of 38 

Descent  of  ovary  as  complication  to  truss  fitting 180 

testicle 34 

abnormalities  of 35 

as  predisposing  cause  of  inguinal  hernia 46 

tunica  vaginalis  as  predisposing  cause  of  inguinal  hernia.  .  .  46 

Diagnosis  of  congenital  umbilical  hernia 32 

femoral  hernia 309 

inguinal  hernia 82 

oblique  inguinal  hernia  from  other    conditions 102 

traumatic  ventral  hernia 388 

umbilical  hernia : 354 

Diagram  for  truss  fitting 1^4 

Diaknow,  P.  T.,  M.D 375 


450  INDEX. 

PAGE 

Diaphragmatic  hernia 412 

Differential  diagnosis,  between  femoral  and  inguinal  hernia iii 

femoral  hernia 310 

strangulated  inguinal  hernia 423 

types  of  inguinal  hernia gi 

Difficulties  of  mechanical  treatment  of  femoral  hernia 317 

Direct  inguinal  hernia 57 

differentiated  from  other  inguinal  hernia 97 

Divisions  of  umbilical  hernia 344 

Donati,  Marie 59 

Dot}^  Dr.  George  E 80,  261 

Double  truss 147 

Double  French  truss  in  femoral  hernia 328 

Dowd,  Dr.  Chas.  N 400 

Drainage  after  hernia  operations 226 

Dressings  after  hernia  operations 226 

Dummy  pad  on  truss 141 

Duodeno-jejunal  recess 412 

E 

Eccles,  W.  McAdam,  M.S 35,   36,   383,  423 

Elastic  truss  in  femoral  hernia 327 

inguinal  hernia 121 

English  truss 121 

for  femoral  hernia 325 

for  inguinal  hernia 124 

for  umbilical  hernia 369 

Enlarged  veins  as  complication  to  operation  for  inguinal  hernia 239 

Enterocele 20 

Entero-epiplocele 20 

Epiplocele 20 

Excelsior  truss  for  femoral  hernia 326 

External  abdominal  ring 23 

iliac  artery 29 

inguinal  ring 31 

oblique  muscle 22 

pudic  vessels 22 

F 

Fat  as,  complication  of  operation  for  oblique  ingtiinal  hernia 239 

contra-indication  of  operation  of  abdominal  hernia 409 

predisposing  cause  of  hernia 49 

Femoral  hernia 297 

age  relation  to 18 

anatomy  of 298 

combined  with  inguinal  hernia 340 

contents  of 309,  333 

danger  of 297,  306 

definition  of 17 

diagnosis  of 309 

differentiated  from  inguinal  hernia iii,  316 

fitting  truss  for 324 

formation  of 304 

irreduci1)le 316 

truss  for 329 

mechanical  treatment 317 

percentage  of 18 


INDEX.  451 

PAGE 

Femoral  hernia,  post-operative  treatment  of 340 

sex  relation  to 18 

shape  of  sac  of 308 

strangulated 439 

medical  treatment  of 440 

operation  for 444 

symptoms  of 439 

taxis  in 44° 

surgical  treatment 331 

history  of 331 

prognosis  of 333 

technique  of 334 

symptoms 309 

time  of  occurrence 297 

Femoral  ring 299 

sheath 301 

Ferguson,  Dr.  R 256 

Finding  hernial  sac 220 

Fitting  trusses  for  femoral  hernia 324 

inguinal  hernia 152 

complication  in 173 

Foramen  of  Winslow  hernia 412 

Formation  of  femoral  hernia 304 

French  trusses 124 

Function  of  delayed  testicle 39 

G 

Garangeot 309 

Genital  mass,  primary  location  of 34 

transition  of 34 

Genito-crural  nerve 26,  43 

German  trusses  for  femoral  hernia 325 

inguinal  hernia 124 

umbilical  hernia 356 

Gibson,  Dr.  C.  L 284,    290,  436 

Gimbernat's  ligament 23,  299 

Goldner 29,  410 

Gordon 124 

Gubernaculum  testis 35 

Gymnastic  treatment  of  inguinal  hernia 204 

Seaver's  views  on 206 

H 

Haberen 314 

Halsted,  Dr.  W.  vS 228,   237,  238 

Heaton,  Geo.  M.D 213 

Heredity  as  a  predisposing  cause  of  hernia 44 

Hernial   dyspepsia 345 

Zabe  on 345 

Hinged  Cup  truss 186 

History  of  trusses 116 

Hood,  Dr.  J.  W.,  trusses 136 

for  femoral  hernia 326 

inguinal  hernia 128,  136 

their  advantages 142 

Horwitz,  Dr.  Orville 291 


452  INDEX. 

PAGE 

Hydrocele  differentiated  from,  femoral  hernia 315 

inguinal  hernia. 108 

congenital  differentiated  from  inguinal  hernia 104 

Hypogastric  f ossas 31 

I 

Ilio-hypogastric  nerve 26,  30 

Ilio-inguinal  nerve 26,  30 

Impulse  of  inguinal  hernia 85 

Incarcerated  inguinal  hernia 70 

Incision  for  combined  inguinal  and  femoral  hernia 340 

Incomplete  hernia 54 

Infantile  hernia 75 

Infant  umbilical  hernia  treatment 355 

Inflamed  inguinal  hernia 70 

Inflamed  glands  differentiated  from  strangulated  inguinal  hernia.  .  .  423 

Infundibuiiform  fascia 27,  42 

Inguinal  adenitis  differentiated  from  oblique  inguinal  hernia no 

Inguinal  canal 27 

Inguinal  hernia,  age  relation  to 18 

anatomy  of 20 

Andrews'  operation  for ' 227 

author's  operation  for 218 

Bassini's  operation  for 216 

combined  with  femoral  hernia 340 

curative  treatment  for 113 

definition 17 

diagnosis  of 82 

differential 102 

differentiated  from  femoral  hernia in 

percentage  of 18 

sac  of 71 

sex  relation  to 18 

strangulated 413 

differential  diagnosis  of 423 

taxis ; 428 

treatment  of 427,  432 

gymnastic 204 

mechanical 114 

surgical 214 

types  of 54 

Inguino-perineal  hernia 36 

Injection  of  hernia 212 

Instructions  to  truss  wearers 201 

Intercolumnar  fascia 23,  43 

Internal  aV)dominal  ring 27 

hernia 412 

inguinal  hernia 31 

oblique  muscle 24 

secretion  of  testicle.  . 39 

Interparietal  hernia 63 

Intersigmoid  recess 412 

Interstitial  hernia 63 

complicating  truss  fitting 180 

Invagination  of  scrotal  tissue  in  diagnosis  of  inguinal  hernia 86 

Irreducible  hernia 19,  20 

femoral 316 


INDEX.  453 

PAGE 

Irreducible  femoral  hernia,  truss  for 329 

inguinal 68 

strangulated 414 

umbilical 370 

tumor  differentiated  from  oblique  inguinal  hernia 108 

J 

Johnson,  Dr.  George  Ben.,  views  on  operation  for  umbilical  hernia.  .  372 

K 

Kangaroo  tendon 217 

Kelley,  Dr.  Samuel  W 356 

Kelly,  Dr.  Howard 391 

Kingdon,  Mr 399 

Kocher 231 

L 

Labial  hernia 55 

varix  differentiated  from  oblique  inguinal  hernia 105 

Lavater's  hernia 422 

Lead  tape  method  of  measuring  for  truss 154 

Lifting  as  direct  cause  of  hernia 51 

Ligation  of  blood  vessels  in  inguinal  hernia 219 

hernial  sac 222 

Lindf ors 381 

Lipoma  differentiated  from  femoral  hernia 312 

oblique  inguinal  hernia 109 

Littres  hernia 422 

Location  of  spontaneous  ventral  hernia 384 

stricture  in  strangulated  inguinal  hernia 414 

Lockwood,  C.  B 45,  385 

Lumbar  hernia 398 

M 

Macdonald,  Dr.  Willis 382 

Macfadden,  Bernard ' .  .  .  211 

Macready,  Jonathan,  F.  C.  H ..  .    124,    186,   297,   309,   383,   398,   405,  406 

McLachlan 288 

Marcy,  Dr.  Henry  0 217 

Mathews,  Dr.  Wm.  P 255 

Mayo,  Dr.  Wm.  J.,  operations  for  umbilical  hernia 377 

Measuring  for  truss 152 

Mechanical  treatment  for,  femoral  hernia 317 

inguinal  hernia 114 

in  infancy 189 

when  irreducible 183 

lumbar  hernia 399 

umbilical  hernia 355 

in  adults 360 

in  fat  subjects 368 

ventral  hernia 392 

Medical  treatment  for  strangulated  hernia 427 

Mesentery 31 

length  of 50 

Method  of  examination  for  inguinal  hernia 84 


454  INDEX. 

PAGE 

Moc-Main  truss 121 

Mortality  from  operation  for  femoral  hernia 332 

Mouth  of  hernia 19 

N 

Neck  of  hernia 19 

Needle  for  femoral  hernia 342 

Night  trusses 124 

Noble,  Dr.  Charles  P 292 

Nuck,  Dr 42 

O 

Oblique  inguinal  hernia 54 

acquired  differentiated  from  other  types  of  inguinal  hernia 94 

Obturator  hernia 403 

Occurrence  of  abdominal  hernia 17 

Ody,  Salmon  and 129 

Omentum 31 

Opening  of  hernial  sac 222 

Operations  for,  bladder  hernia 286 

csecal  hernia 280 

delayed  testicle  with  inguinal  hernia 247 

femoral  hernia 331,  334 

combined  with  inguinal  hernia 340 

inguinal  hernia 228,  237 

sigmoid  hernia 280 

umbilical  hernia 373 

Orchitis  differentiated  from  strangulated  inguinal  hernia 423 

Overlapping  abdominal  wall  in  umbilical  hernia 375 

P 

Pads,  truss 148 

Palliative  treatment  of  inguinal  hernia 113 

Pancoast 213 

Partial  enterocele 422 

Percentage  of  various  forms  of  hernia 18 

Peritoneum 30 

Peritonitis  as  complication  to  hernia  operation 412 

Petit's  triangle 277,  398 

Phimosis  as  direct  cause  of  hernia 53 

Physical  signs  of  strangulated  inguinal  hernia 415 

Pillars  of  external  abdominal  ring 23 

Plastic  operation  for  femoral  hernia 343 

Plummcr,  Dr.  S.  C 286 

Post-operative  treatment  for  femoral  hernia 340 

umbilical  hernia 381 

Post-operative  hernia 19 

Posture  as  direct  cause  of  hernia 51 

Poupart's  ligament 23,  298 

Powder  for  truss  wearers 202 

Pregnancy  as  complication  to  operation 295 

to  truss  fitting 181 

Preparation  for  operation 215 

Prognosis  of  femoral  hernia 333 

inguinal  hernia 114 

obturator  hernia 405 


INDEX.  455 

PAGE 

Prognosis  of  strangulated 421 

femoral 439 

inguinal 425,  438 

umbilical 443 

umbilical  hernia 368 

in  infants 357,  372 

ventral  hernia 396 

Properitoneal  hernia 63 

Q 

Quin,  Nicola  C 124 

R 

Radical  cure  truss 167 

Rare  hernia,  lumbar 398 

obturator 403 

sciatic 405 

strangulation  of 445 

vaginal 408 

Rat-tail  truss 170 

Rectus  muscle 26 

Recurrences  after  operation  for  femoral  hernia 332 

Reducible  hydrocele  as  complication  to  fitting  truss 175 

Reducibility  of  non-strangulated  inguinal  hernia 68,   82 

Repair  of  bladder  wounds 290 

Results  of  operations  for  inguinal  hernia 235 

failure  of  obliteration  of  tunica  vaginalis 39 

Retaining  pads 148 

Retraction  of  testicle 43 

Retro-vesical  hernia 412 

Richter's  hernia 422 

Rigg's,  Dr.  J.  W 151 

Round  ligament  in  female  inguinal  hernia 293 

Rupture 17 

S 

Salmon  and  Ody 129 

Sapiejhko,  Dr 375 

Sciatic  hernia 405 

Scrotal  hernia 55 

truss 166 

Seaver,  Jay  W.,  A.M.,  M.D 204 

Secondary  hemorrhage  as  complication  to  hernia  operation 411 

Selection  of  truss • 161 

for  infants 194 

direct  inguinal  hernia 172 

oblique  inguinal  hernia i6r 

Separation  of  hernial  sac 222 

Sepsis  as  complication  to  operation  for  abdominal  hernia 412 

Sex  as  predisposing  cause  of  hernia 45 

relation  to  various  forms  of  hernia 18 

Shape  of  sac  of  femoral  hernia 308 

Shaping  truss  for  femoral  hernia 317 

inguinal  hernia 152,  157 

Shouting  as  direct  cause  of  hernia 51 

Sigmoid  hernia 60,    277,  279 


456  INDEX. 

PAGE 

Sigmoid  hernia  diflferentiated  from  other  inguinal  hernia 98 

operation  for 280 

Silk  as  suture  materia] 217 

Situation  of  umbilical  hernia 344 

Size  as  complication  to  operation  for  inguinal  hernia 265 

contra-indication  to  operation  for  abdominal  hernia 409 

of  umbilical  hernia. 346 

Spermatic  cord 29 

constituents  of 42 

Spontaneous  ventral  hernia ^8^ 

Strangulated  hernia 427 

femoral  hernia 439 

inguinal  hernia 70,  413 

rarer  hernia 444 

umbilical  hernia 443 

Sub-peritoneal  areolar  tissue 27 

fat  as  complication  to  truss  fitting 174 

Summary  of  author's  operations  for  abdominal  hernia 445 

Superficial  epigastric  vessels 22 

fascia 21 

vessels  of 22 

Stirgical  anatomy  of  inguinal  region 20 

Svu-gical  treatment  of,  femoral  hernia 331 

inguinal  hernia 214 

Andrews'  operation  for 227 

author's  operation  for 218 

Bassini's  operation  for 216 

Halsted's  operation  for 228 

in  female 292 

lumbar  hernia 400 

strangulated  hernia 432 

iimbilical  hernia 372 

author's  operation  for 373 

Blake's  operation  for 375 

Dr.  Johnson's  views  on 372 

Mayo's  operation  for 377 

ventral  hernia 396 

Symptoms  of  bladder  hernia 285 

femoral  hernia 309 

inguinal  hernia 82 

spontaneous  ventral  hernia 384 

strangulated  hernia 416 

umbilical  hernia 354 

T 

Taylor,  Dr.  Geo.  H 211 

Dr.  William  J i 3^4 

Taxis 428 

on  umbilical  hernia 444 

Testicle 34 

Theory  of  operation  for  inguinal  hernia 214 

Thrornbosis  of  femoral  vein  as  accident  to  hernia  operations 410 

Time  of  occitrrence  of  femoral  hernia 297 

Time  of  oVjliteration  of  tunica  vaginalis 39 

Tod.  Dr 147 

Traction  in  reduction  of  hernia 429 

Transversalis  fascia 27 


INDEX.  457 

PAGE 

Transversalis  muscle  in  inguinal  hernia 25 

Traumatic  ventral  hernia 386 

Trautmann 80 

Treatment  of  femoral  hernia 317 

inguinal  hernia 113 

lumbar  hernia 399 

umbilical  hernia 355 

congenital 382 

traumatic  ventral  hernia 392 

Trusses,  classification  of 116 

construction  of 116 

coverings  of 151 

fitting  of 152 

for  bladder  hernia 277 

for  caecal  hernia 277 

for  femoral  hernia 317 

for  infants 194 

for  inguinal  hernia 116 

for  sigmoid  hernia 277 

for  umbilical  hernia 358 

for  ventral  hernia 393 

instructions  to  wearers  of 201 

varieties  of 121 

Tuberculosis  as  contra-indication  to  operating  abdominal  hernia.  ...  410 

Tuffier 278 

Tumors  differentiated  from  femoral  hernia 316 

Tunica  vaginalis 39 

cysts  of 40 

Types  of  hernia '54 

U 

Umbilical  hernia 344 

age  relation  to 18 

anatomy  of 345 

contents  of 349 

definition  of 17 

irreducible 370 

percentage  of 18 

sex  relation  to 18 

strangulation  of 443 

symptoms  of 354 

taxis  on 444 

treatment  of 355 

infant. 355 

mechanical 355 

surgical 372 

Unclassified  trusses 147 

Undescended  ovary  differentiated  from  oblique  inguinal  hernia no 

Undescended  testicle,  see  delayed  testicle 37 

Urinary  obstruction  as  direct  cause  of  hernia 52 

V 

Vaginal  hernia 408 

Varicocele  as  complication  to  operation  for  inguinal  hernia 239 

complication  to  truss  fitting 176 

differentiated  from  femoral  hernia 311 

inguinal  hernia 104 


458  INDEX. 

PAGE 

Vas  deferens 43 

Velpean 213 

Ventral  hernia 383 

causes  of 383 

definition  of 18,  383 

percentage  of 18 

spontaneous 383 

symptoms  of 384 

treatment  of 385 

traumatic 386 

symptoms  of 388 

treatment  of 392 

Vomiting  as  direct  cause  of  hernia 50 

W 

Winsboro,  Dr.  Rudolph 288 

Witzel,  Oscar 386 

Wofler 236 

Wood,  Dr.  Alfred  C 309 

WuUstein 234 

Z 

Zabe,  Dr.,  Hernial  dyspepsia 345 


RD  621036  1907  P  """"*""" 

"la- Its  cliannn 

■iiiiii 

2002098296 


